Diabetes Care Coordinator

1 week ago

Philadelphia, United States Esperanza Health Center Full time
Job DescriptionJob Description

POSITION SUMMARY: The Diabetes Care Coordinator leads the coordination of holistic health services for patients with diabetes at Esperanza Health Center (EHC). This includes but is not limited to: tracking and assisting patients with completing recommended screenings to prevent complications from diabetes; maintaining up-to-date lists of resources and devices available to patients to help control their diabetes; and assisting with other diabetes-related initiatives at EHC. The Diabetes Care Coordinator also assists with the referral of patients to and the coordination of diabetes prevention programs.

ESSENTIAL FUNCTIONS

  • Work with Clinical Medical Director and QA Associate Medical Directors to track and plan strategies to improve diabetes clinical quality measures and to improve metrics related to diabetes.
  • Track and monitor patients with uncontrolled diabetes to ensure adequate follow up is achieved; collaborate with Diabetes Patient Navigator to achieve this.
  • Track and monitor patients overdue for diabetes labs to ensure adequate follow up is achieved; collaborate with Diabetes Patient Navigator to achieve this..
  • Order lab work as permitted in standing orders to monitor patients diabetes.
  • Work with supervisor to explore and coordinate outside partnerships and events as needed, such as with health insurance companies, to facilitate the completion of recommended health screenings for patients with diabetes (including but not limited to retinal screening clinics).
  • Connect patients to resources to assist them in controlling their diabetes, including but not limited to:
    • Nutrition classes or visits
    • EHC Lifestyle Medicine classes
    • Devices to monitor their sugar, such as glucometers, lancets, etc.
  • Assess patients’ Social Drivers of Health (SDOH) and connect them with necessary resources.
  • Communicate with patients’ PCP and other care team members about updates to the patients health and any potential barriers to treating their diabetes.
  • Ensure deliverables for any grant partnerships are met.
  • Collaborate with Esperanza health care team members (e.g. behavioral health, social services) and outside agencies (e.g. The Simple Way, Manna, etc) as needed to address barriers to controlling diabetes.
  • Collaborate with outside organizations to refer patients to and support the Diabetes Prevention Program as needed.
  • Assess project trends by tracking system data to determine appropriate changes to program strategy, in collaboration with Clinical Medical Director and QA Associate Medical Director.


COMPETENCIES
  • Self-directed and motivated.
  • Ability to effectively provide clinical care to socially and medically complex patients in a variety of non-traditional settings
  • Exceptional organizational and interpersonal skills, with attention to detail required.
  • Strong written oral/written communication is required.
  • Competency in Google Suite, knowledge of database and data analysis preferred.
  • Ability to work collaboratively in a team and manage multiple priorities, utilize effective time management skills, and exercise sound administrative and clinical judgment.
  • Ability to analyze systems and to develop creative solutions to problems.
  • Demonstrated cultural humility, strong cross-cultural sensitivity and experiences, required.
  • Requires the ability to travel to multiple office locations.
  • Provides effective spiritual intervention with patients, sharing hope and salvation through Jesus Christ, sharing helpful Biblical instruction and scriptures, praying for patients, and connecting/referring to Christian churches as appropriate and according to the leading of the Holy Spirit. Does not force spiritual intervention, but gives spiritually uninterested patients respect and space, continuing to provide exemplary care in all other dimensions.
  • Serves all patients in a Christ-like manner, with respect, humility, love, and self- control.

KNOWLEDGE, SKILLS, AND QUALIFICATIONS
  • High school diploma or equivalent.
  • At least 1-2 years’ experience providing services in a healthcare setting.
  • Supervisory experience preferred
  • Spanish language proficiency required
  • Demonstrable maturity and professionalism in the workplace.
  • Knowledge of North Philadelphia communities, an understanding of the barriers to health and experience supporting individuals with behavior change preferred.

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