Health - Diabetes Case Specialist

Job Description

Job Description

POSITION SUMMARY: The Diabetes Case Specialist, under the direction of the Rural Health Program Manager, is responsible for providing quality information, skills, support, and other resources that empower patients to perform diabetes self-care and make choices that will lead to primary or secondary prevention and good diabetes control. The position is responsible for providing health promotion/disease prevention community health nursing services based on current community health nursing concepts and standards of practice for members of the Sault Ste. Marie Tribe of Chippewa Indians to include direct in-home, office, clinic, school, and work setting services for individuals and groups.

ESSENTIAL FUNCTIONS: (includes, but is not limited to, the following)

Coordinates care for patients with diabetes, ensuring timely access to necessary medical services, including medical appointments, educational programs, nutritional counseling, and physical activity.

• Develops, implements, and regularly updates individualized care plans in collaboration with the diabetes care team.
• Monitors patient progress, assesses ongoing needs, and adjusts care plans as necessary to meet health objectives.
• Educates patients and their families about diabetes management, including medication adherence, dietary recommendations, and lifestyle changes.
• Facilitates patient self-management by providing tools and resources to empower patients in their care.
• Schedules and coordinates patient appointments with various healthcare providers, ensuring a cohesive approach to diabetes management.
• Maintains comprehensive records of patient interactions, treatments, and outcomes using electronic health records (EHR).
• Collaborates with other healthcare professionals to share information and coordinate services.
• Identifies barriers to care and assists in developing strategies to overcome these challenges.
• Participates in community outreach and education initiatives to raise awareness about diabetes prevention and management.
• Provides one-on-one education for patients referred to with diabetes and other health conditions.
• Provides case management for patients referred with diabetes and other health conditions to meet health care needs.
• Participates in the planning, implementation, and evaluation of group or community diabetes and general education activities.
• Assists the Diabetes Program Manager with meeting grant and program management requirements.
• Writes educational articles for the Tribal paper and the program's website
• ADDITIONAL RESPONSIBILITIES: (includes, but is not limited to, the following)
• Provides recommendations for diabetes care and education consistent with current standards of care per the American Diabetes Association and Endocrine Society.
• All other job-related duties as assigned.

CONTACTS:

Immediate peers, peers in other departments, immediate supervisor/manager, managers in other departments, patients, outside vendor/service providers, Indian Health Service, and other agency grantors.

PHYSICAL REQUIREMENTS:

Position heavy with lifting of 50 pounds maximum with frequent lifting/carrying up to 50 pounds. Physical factors include constant use of hearing, smell, near/midrange/far vision, depth perception, color/field of vision; frequent standing, walking sitting, pushing/pulling, climbing, stooping kneeling, reaching, manual handling, driving, typing, bending and assisting clients from sitting/lying positions to standing positions. Working conditions include constant exposure to weather, extreme heat/cold, wet/humidity, noise, and air quality. Potential hazards include constant client/patient contact, computer use, and equipment use. Personal Protective Equipment includes protective eyewear, gowns, masks, and gloves.

REQUIREMENTS:

Education: Bachelor’s Degree – RN Licensure in the State of Michigan required.

Experience: Minimum of three (3) years of experience in hospital, long-term care, ambulatory care, or home health setting required.

Certification/License: Certification as a Diabetes Educator (CDE) is preferred. Will be required to undergo and successfully pass a background check. Must maintain a good moral character standing. Must have a valid driver’s license and be insured by the Sault Tribe Insurance Department. Must comply with annual driver’s license review and insurability standards with the Sault Tribe Insurance Department. Will be required to complete and pass pre-employment drug testing.

Knowledge, Skills, and Abilities: Knowledge of HIPAA and confidentiality standards is required. Knowledge of the current American Diabetes Association's and American College of Endocrinology's standards of diabetes care is preferred. Knowledge and ability to use word processing and spreadsheet and database software required. Knowledge of electronic health records is preferred. Nursing assessment skills, scope of practice, and critical thinking are required. Must have excellent organization skills, organizing work, prioritizing tasks managing time, and meeting goals promptly. Must be able to communicate effectively, verbally and in writing, in a diverse range of audiences and settings. Must be able to establish and maintain effective communication with co-workers, supervisors, customers, and the general public. Group education and presentation skills are required. Must maintain confidentiality. Native American preferred.