Chronic Disease Management Nurse Specialist

4 days ago


Philadelphia, Pennsylvania, United States Spectrum Health Services Full time

About the Role

Spectrum Health Services is seeking an experienced Chronic Disease Management Nurse to join our team. This role is a key part of our efforts to develop and implement structured disease management programs, starting with self-measured blood pressure.

Key Responsibilities

  • Develop and implement disease management programs in collaboration with leadership
  • Track and respond to patient referrals, providing education on self-monitoring equipment, medication adherence strategies, and lifestyle changes
  • Manage onsite devices and relationships with DME vendors to provide devices to patients
  • Review telemonitoring results and provide education on medication regimens, dietary strategies, and physical activity for chronic disease management
  • Work with patients to develop SMART goals around chronic disease self-management using motivational interviewing techniques
  • Conduct proactive outreach to patients to check on self-monitoring and medication adherence, goal progress, and assess for barriers, issues, or concerns
  • Flag and review out-of-range readings with providers, work with providers to titrate meds between visits, educate patients on regimen changes, and ensure new medications are obtained
  • Field incoming calls from enrolled patients
  • Collaborate with Directors of Clinical Informatics and Quality Measures, Care Management and Population Health to track and report program data
  • Participate in meetings related to HCCN-wide initiatives and grants around chronic disease self-management programs
  • Develop patient-friendly educational materials with the marketing team and registered dietician
  • Provide one-off education for patients with new chronic disease diagnoses or new medications needed to manage those illnesses
  • Work with the clinical nursing team to orient to demo devices, educational materials, and medications
  • Other duties as assigned

Qualifications

  • BSN degree or higher
  • At least 3-5 years clinical nursing experience
  • Strong Microsoft Excel skills
  • Experience documenting in electronic medical records
  • Strong knowledge of chronic disease management, including hypertension, diabetes, asthma, CHF, COPD medications and lifestyle management
  • Motivational interviewing experience
  • Ability to interact with individuals with diverse cultural, linguistic, and religious backgrounds
  • Ability to travel between sites as needed

About the Opportunity

This role offers a competitive salary of $83,000 - $110,000 per year, depending on experience, and a comprehensive benefits package.



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