Chronic Disease Management Nurse Specialist
4 days ago
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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