Disease Management Nurse Specialist

4 days ago

Philadelphia, Pennsylvania, United States Spectrum Health Services, Inc Full time
Job Title: Disease Management Nurse

Job Summary:

The Disease Management Nurse will collaborate with patients and healthcare providers across Spectrum Health Services, Inc. to provide chronic-disease self-management support to patients between visits. The nurse will provide in-person and virtual chronic disease self-management education, support a panel of patients in remote monitoring programs, develop educational materials, track program metrics, and participate in collaborative projects with community-based organizations and other health centers to improve the health and wellbeing of Spectrum's patient population.

Key Responsibilities:

  • Work with leadership to develop and implement structured disease management programs, starting with self-measured blood pressure. Future programs will focus on diabetes, asthma, and potentially other chronic disease states, such as CHF and COPD.
  • Track and respond to patient referrals, meeting patients in-person and virtually to enroll in program. Instruct in use of self-monitoring equipment, medication adherence strategies, and lifestyle strategies for self-management.
  • Manage onsite devices and relationship with DME vendor to provide devices to patients.
  • Receive and review telemonitoring results.
  • Provide patient education regarding their medication regimen, medication adherence strategies, dietary strategies for self-management, physical activity strategies for management, and appropriate lifestyle changes such as smoking or alcohol cessation, sleep hygiene, or weight management.
  • Work with patients to develop SMART goals around chronic disease self-management, using motivational interviewing techniques and supportive coaching to assist patients in achieving goals.
  • Conduct proactive outreach to patients at scheduled cadence to check in on self-monitoring and medication adherence, goal progress, and assess for any barriers, issues, or concerns.
  • Serve as intermediary between patient and provider to troubleshoot barriers, issues, and concerns between visits.
  • Flag and review out-of-range readings with provider, work with provider to titrate meds between visits adhering to established nurse-driven protocols, educate patient on regimen changes, and ensure new meds obtained.
  • Field incoming calls from enrolled patients.
  • Work with Director of Clinical Informatics and Quality Measures and Director of Care Management and Population Health to track and report program data.
  • Work with Director of Care Management and Population Health to develop templates to document program data in EHR.
  • Participate in meetings related to HCCN-wide initiatives and grants around chronic disease self-management programs.
  • Work with marketing team and Registered Dietician to develop patient-friendly, health literacy-forward print educational materials and vet pre-made educational resources.
  • Develop Spectrum library of demo devices, including BP cuffs, demo BG monitors, demo insulin pens and administration pads, demo inhalers.
  • Provide one-off education for patients with new chronic disease diagnoses or new medications needed to manage those illnesses.
  • Work with clinical nursing team to orient to demo devices, educational materials, meds, self-monitoring equipment so that they can also provide face-to-face education to patients being seen for visits.
  • Work to obtain free, gently used equipment for distribution to patients with insurance barriers to obtaining equipment.

Qualifications/Experience:

  • BSN degree or higher.
  • At least 3-5 years clinical nursing experience.
  • Strong Microsoft Excel skills.
  • Experience documenting in electronic medical record.
  • 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.

Preferred Experience:

  • Experience in home health, ambulatory care, care management, or patient education.
  • Knowledge of public benefits and community resources across Philadelphia.
  • Basic understanding of Medicaid and Medicare durable medical equipment (DME) coverage.
  • Familiarity with remote patient monitoring programs.

  • Disease Management Nurse Specialist

    4 weeks ago

    Philadelphia, Pennsylvania, United States Spectrum Health Services, Inc Full time

    Job Title: Disease Management NurseSpectrum Health Services, Inc is seeking a highly skilled and compassionate Disease Management Nurse to join our team. As a key member of our healthcare team, you will play a vital role in providing chronic disease self-management support to patients across our sites.Job Summary:The Disease Management Nurse will work...

  • Disease Management Nurse Specialist

    2 weeks ago

    Philadelphia, Pennsylvania, United States Spectrum Health Full time

    Job SummaryThe Disease Management Nurse will collaborate with patients and healthcare providers across Spectrum sites to provide chronic-disease self-management support to patients between visits. This role involves providing in-person and virtual education, supporting patients in remote monitoring programs, developing educational materials, tracking program...

  • Infectious Disease Specialist

    2 weeks ago

    Philadelphia, Pennsylvania, United States AbsoluteCare Full time

    Job SummaryWe are seeking an experienced Infectious Disease Physician to join our team at AbsoluteCare. As a key member of our multidisciplinary team, you will provide high-quality patient care, develop and implement comprehensive care plans, and work collaboratively with other healthcare professionals to ensure seamless transitions of care.Key...

  • Infectious Disease Specialist

    3 weeks ago

    Philadelphia, Pennsylvania, United States AbsoluteCare Full time

    Job SummaryWe are seeking a highly skilled Infectious Disease Physician to join our team at AbsoluteCare. As a key member of our multidisciplinary team, you will provide comprehensive care to patients living with HIV and other chronic infectious diseases.Key ResponsibilitiesProvide patient consultation and primary management of HIV and other chronic...

  • Infectious Disease Specialist

    1 month ago

    Philadelphia, Pennsylvania, United States AbsoluteCare Full time

    Job SummaryWe are seeking an experienced Infectious Disease Physician to join our team at AbsoluteCare. As a key member of our multidisciplinary care team, you will provide comprehensive care to patients living with HIV and other chronic infectious diseases.Key ResponsibilitiesDevelop and implement diagnostic and treatment care plans for patients with HIV...

  • Surveillance Coordinator – Waterborne Diseases Specialist

    3 weeks ago

    Philadelphia, Pennsylvania, United States Public Health Management Corporation Full time

    Job SummaryThe Public Health Management Corporation is seeking a highly skilled and experienced Waterborne Disease Surveillance Coordinator to join our team. This is a full-time position within the Acute Communicable Disease (ACD) program of the Division of Disease Control (DDC), Philadelphia Department of Public Health (PDPH).Key ResponsibilitiesCoordinate...

  • Surveillance Coordinator – Waterborne Diseases Specialist

    4 weeks ago

    Philadelphia, Pennsylvania, United States Public Health Management Corporation Full time

    Job SummaryThe Public Health Management Corporation is seeking a highly skilled Surveillance Coordinator – Waterborne Diseases to join our team. This is a full-time position within the Acute Communicable Disease (ACD) program of the Division of Disease Control (DDC), Philadelphia Department of Public Health (PDPH).Key ResponsibilitiesCoordinate...

  • Surveillance Coordinator

    2 months ago

    Philadelphia, Pennsylvania, United States Public Health Management Corporation Full time

    Job SummaryThe Public Health Management Corporation is seeking a highly skilled and experienced Surveillance Coordinator to join our team. As a Surveillance Coordinator, you will play a critical role in the prevention and control of waterborne diseases in our community.Key ResponsibilitiesCoordinate surveillance and investigation of waterborne diseases,...

  • Infectious Disease Specialist

    1 week ago

    Philadelphia, Pennsylvania, United States AbsoluteCARE Inc Full time

    Job SummaryWe are seeking a highly skilled Infectious Disease Physician to join our team at AbsoluteCare, Inc. As a key member of our multidisciplinary care team, you will provide comprehensive care to patients living with HIV and other chronic infectious diseases.Key ResponsibilitiesProvide patient consultation, primary management, and ongoing treatment of...

  • Metabolic Disease Specialist

    5 days ago

    Philadelphia, Pennsylvania, United States Children's Hospital of Philadelphia (CHOP) Full time

    Job Title: Outpatient MetabolismJob Summary:We are seeking a highly skilled and dedicated Advanced Practice Provider to join our team at the Children's Hospital of Philadelphia (CHOP). The ideal candidate will have a strong background in metabolic disease and a passion for providing exceptional patient care.Responsibilities:Preparation for Clinic Visits:...

  • Advanced Practice Infectious Disease Specialist

    5 days ago

    Philadelphia, Pennsylvania, United States AbsoluteCARE Inc Full time

    Job Title: Advanced Practice Infectious Disease ProviderAt AbsoluteCare Inc., we are seeking an experienced Advanced Practice Infectious Disease Provider to join our team. As a key member of our care team, you will provide high-quality patient care, working closely with our multidisciplinary team to deliver comprehensive care to our patients.Job Summary:This...

  • Advanced Practice Infectious Disease Specialist

    1 month ago

    Philadelphia, Pennsylvania, United States AbsoluteCARE Inc Full time

    Job SummaryWe are seeking an experienced Advanced Practice Infectious Disease Provider to join our team at AbsoluteCare Inc. As a key member of our care team, you will provide comprehensive care to patients living with HIV and other chronic infectious diseases.Key ResponsibilitiesProvide patient consultation and primary management of chronic infectious...

  • Nurse Care Manager

    3 weeks ago

    Philadelphia, Pennsylvania, United States Evergreen Nephrology Full time

    About the RoleWe are seeking a highly skilled and compassionate Nurse Care Manager to join our team at Evergreen Nephrology. As a key member of our interdisciplinary team, you will play a vital role in delivering high-quality, patient-centered care to individuals with kidney disease.Key ResponsibilitiesCollaborate with physicians, advanced practice...

  • Surveillance Coordinator for Waterborne Diseases

    4 days ago

    Philadelphia, Pennsylvania, United States Public Health Management Corporation Full time

    About the RoleThe Public Health Management Corporation is seeking a highly skilled Surveillance Coordinator to join our team in the Acute Communicable Disease Program. As a key member of our team, you will play a critical role in the surveillance, investigation, and prevention of waterborne diseases in Philadelphia.Key ResponsibilitiesCoordinate surveillance...

  • Waterborne Disease Surveillance Coordinator

    3 weeks ago

    Philadelphia, Pennsylvania, United States Public Health Management Corporation Full time

    Job SummaryThe Public Health Management Corporation (PHMC) is seeking a highly motivated and detail-oriented Waterborne Disease Surveillance Coordinator to join our team. As a key member of our Acute Communicable Disease (ACD) program, you will play a critical role in the surveillance, investigation, and prevention of waterborne diseases in...

  • Public Health Waterborne Disease Coordinator

    2 weeks ago

    Philadelphia, Pennsylvania, United States Public Health Management Corporation Full time

    Job SummaryThe Public Health Management Corporation is seeking a highly skilled and experienced Surveillance Coordinator to join our team. As a Surveillance Coordinator, you will play a critical role in the prevention and control of waterborne diseases in our community.Key ResponsibilitiesCoordinate surveillance and investigation of waterborne diseases,...

  • Surveillance Coordinator – Waterborne Diseases

    5 days ago

    Philadelphia, Pennsylvania, United States Public Health Management Corporation Full time

    Job SummaryThe Public Health Management Corporation is seeking a highly skilled Surveillance Coordinator – Waterborne Diseases to join our team. As a key member of our Acute Communicable Disease (ACD) program, you will play a critical role in the surveillance, investigation, prevention, and control of waterborne diseases.Key ResponsibilitiesCoordinate...

  • Surveillance Coordinator – Waterborne Diseases

    3 weeks ago

    Philadelphia, Pennsylvania, United States Public Health Management Corporation Full time

    Job SummaryThe Public Health Management Corporation is seeking a highly skilled Surveillance Coordinator – Waterborne Diseases to join our team. As a key member of our Acute Communicable Disease (ACD) program, you will play a critical role in the surveillance, investigation, prevention, and control of waterborne diseases.Key ResponsibilitiesCoordinate...

  • Infectious Disease Specialist

    1 month ago

    Philadelphia, Pennsylvania, United States AbsoluteCare Full time

    About the RoleThis is a challenging and rewarding opportunity to join our team at AbsoluteCare as an Infectious Disease Physician. As a key member of our multidisciplinary team, you will play a vital role in providing high-quality patient care and contributing to the development of our population health management strategies.Key ResponsibilitiesProvide...

  • Waterborne Disease Surveillance and Investigation Expert

    2 weeks ago

    Philadelphia, Pennsylvania, United States Public Health Management Corporation Full time

    Job SummaryThe Public Health Management Corporation is seeking a highly skilled and experienced Surveillance Coordinator to join our team. As a key member of our Acute Communicable Disease (ACD) program, you will play a critical role in the surveillance, investigation, and prevention of waterborne diseases in Philadelphia.Key ResponsibilitiesCoordinate...