RN/ LPN Chronic Disease Care Specialist

Job title: RN/ LPN Chronic Disease Care Specialist

Company: Hamilton Health Center

Job description: All About Hamilton Health Center

Hamilton Health Center (Hamilton), established in 1969, is the only Federally Qualified Health Center (FQHC) within a 30-mile radius of Harrisburg, PA and continues to grow using a holistic and comprehensive approach to being patient centered. The mission of Hamilton is to improve the health of Central Pennsylvania’s residents by delivering high quality, respectful and patient-centered health and related social services that promote access, treatment, education, and prevention regardless of health, economic, or insurance status. Our vision is that every member of our community, regardless of their ability to pay or their insurance status, receives holistic, quality health care needed to create a healthy community. For over 50 years we have been true to these words. As part of our team, you will work alongside a dedicated team that cares and values those we serve.

Benefits offered: In addition to your base pay, you are also eligible to receive:

• Paid time off, Catastrophic (CAT)/Sick time, Birthday holiday, and 7 paid holidays.
• Medical, Dental & Vision,
• Company paid life insurance.
• Retirement Plan
• Employee Assistance Program

Job Summary: The Chronic Disease Care Specialist is responsible for providing clinical, consultative and education services for persons with chronic diseases, and provides community health education relative to chronic diseases. Develop programs/curriculum to provide information on the management of chronic diseases for patients of all ages in a manner that will enhance Hamilton’s image and increase customer satisfaction.

Job location: Hamilton Family Care at Millersburg, 1000 Evelyn Dr., Millersburg, PA 17061

Essential duties and Responsibilities:

• Serve as a chronic disease specialist and educator for all clinics.
• Collaborate with the providers and nursing staff by coordinating care and services for chronic disease patients to maximize use of available resources and to offer complete preventative care to those in need.
• Manage gaps in care of chronic disease patients as identified in the electronic health record.
• Participate as a proactive member of the Patient-Centered Coordinated Care (PCCC) model and collaborate with RN coordinators to support the care model.
• Track patient outcomes and provide information to authorized personnel as requested.
• Work with providers and nursing staff to develop plan of care for patients and adjust as needed.
• Coordinates and integrates care of selected populations by managing chronic disease registries and coordinating outreach activities within our community.
• Apply clinical knowledge to support chronic disease management, psychosocial, behavioral health, hospital utilization, pharmaceutical, and social determinants of health barriers.
• Assess, evaluate and measure program goals and outcomes under direct supervision of the Director of Nursing.
• Build and maintain relationships with both internal and external healthcare contacts and organizations to improve available patient resources.
• Maintain electronic medical records (EMR) and other related information and ensure compliance with all State and Federal guidelines.
• Coordinate community outreach education classes as identified.
• Coordinate and review the development and implementation of Chronic Disease Management and services.
• Assist patients in monitoring their disease processes/state.
• Provide education related to identified chronic diseases, including the disease process, medication, diet and nutritional monitoring, prevention and care of complications, and other specific educational needs specific to the disease being addressed.
• Develop and implement educational programs for staff, patients and families Advise patients as to long-term complications.
• Perform effective and productive communication between patients and providers.
• Assess and identify actual and potential patient problems by gathering relative data.
• Assess, monitor, and implement treatment plans for patient at various stages of the chronic disease, with the focus on prevention of complications and maintenance of the disease state.
• Provide ongoing assessment and work with the treatment team and patient/family for adjustments in the plan of care as required.
• Document assessments, interventions and plan including recommendations and goals and progress notes.
• Manage program budgets and grants if applicable.
• Research and identify community health needs; coordinate the planning, implementation and evaluation of campaigns directed toward changing behaviors.
• Act as a Hamilton Health Center liaison with outside entities promoting health improvement initiatives.

Minimum Education/Certifications: Bachelor’s degree in Health/Human Services or related field, required. Must have a current license to practice as a Registered Nurse, Licensed Practical Nurse in the Commonwealth of Pennsylvania. Willingness to become certified as a Chronic Care Professional within 2 years of hire.

Minimum Work Experience: Minimum of three years’ experience in chronic disease management working within a primary or ambulatory care setting. Highly proficient in Microsoft Office and knowledge working with Electronic Medical Records. Ability to clearly communicate issues to all levels of management. Bi-lingual (Spanish) and knowledgeable in The Joint Commission regulations, preferred.

Other Requirements: Valid driver’s license with reliable transportation to travel throughout the service area.

This job description is a general outline of duties performed and is not to be misconstrued as encompassing all duties performed within the position. All individuals (including current employees) selected for a position will undergo a background check appropriate for the position’s responsibilities.

PI208288331

Expected salary:

Location: Millersburg, PA

Job date: Sat, 18 Mar 2023 08:57:40 GMT

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