Description:

SUMMARY:

The Diabetes Community Care Coordinator (DCCC) will provide individualized diabetes self-management education within their documented competency according to the current American Diabetes Association Standards of Care. The DCCC is expected to exercise a high degree of initiative and judgement in providing patient education and follow-up as needed. Coordinates patient care with necessary staff. Bilingual English/Spanish required.

Starting wage is $17 - $19 DOE.

The wage will increase to $19 - $20 DOE once the candidate completes the in-house Diabetes Educator Certification.

Employees can earn up to $520 on the quarterly bonus.

KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED:

1. Excellent organizational skills and strong written and verbal communication skills.

2. Strong computer skills. EHR experience preferred.

3. Ability to build and maintain effective partnerships internally and externally with an awareness of community resources.

4. Ability to work with patient/client groups and/or experience in membership organizations.

5. Ability to work with minimal supervision and maximum accountability to problem-solve and work independently and collaboratively as a member of a team.

6. A professional demeanor, and a pleasant manner in telephone and personal contacts.

7. Analytical skills with the ability to manage and prioritize multiple tasks.

MINIMUM QUALIFICATIONS:

• High school diploma or GED equivalent.
• Evidence of previous experience or training in: diabetes, chronic disease, health and wellness, healthcare, community health, community support, and/or education methods as evidenced by a resume or certificate.
• Excellent verbal, written, and presentation skills.
• Possess good people skills to work with patients, clinical staff, and specialists.
• Spanish Literacy (preferred).
• Medical Assistant, Diet Technician Registered, or BS in medical field preferred.
• Proficient with Microsoft Office Programs.
• Knowledge of local community resources preferred.
• Possess good organizational and time management skills.
• Must be able to exercise discretion and patient privacy.
• Ability to take initiative and work independently and collaboratively as a member of a team.
• Valid Idaho Driver’s License.

DESCRIPTION OF DUTIES:

1. Participate in the delivery of team-based care in assigned clinic(s).

2. Provide comprehensive and follow-up education through an interactive educational style for diabetes education program participants.

3. Evaluate and document attainment of educational objectives.

4. Collaborate with team members for appropriate tracking, follow-up of referrals, and scheduling.

5. Follow FHS policies and procedures in documenting in the EHR.

6. Collect, manage, and review data and develop reports incorporated into the Quality Improvement Programs and as requested for ADA recognition.

7. Work collaboratively with the clinical team, including O&E, Care Managers, and BHCs.

8. Participate in ongoing trainings, learning sessions, conference calls, webinars, and other professional development opportunities.

9. Utilize registries, electronic reports, and review of provider schedules to proactively assess and coordinate preventive screening, care coordination, and communication; document measures and interventions via EHR; and assure that care is patient centered.

10. Use clinical, evidenced-based care guidelines to monitor patient health status and need for services. Coordinate high-risk patient risk reduction, hospital and ER utilization, and improvement of patient outcomes.

11. Use IRIS and Idaho Health Data Exchange to track immunization status and recall for immunizations.

12. Follow up with patients as requested by provider.

13. Assist in education, assistance, support for patients and families, and care coordination with outside providers and community resources.

14. Assess patients’ readiness to change, monitor compliance with plan of care; and problem-solve barriers related to the health care system, and financial and psychosocial barriers.

15. Utilize behavioral strategies to assist patients in adopting health behaviors, improving self-care, and managing chronic disease.

16. Assist Outreach and Enrollment staff with patient’s eligibility requirements for Medicaid, SSI, etc., and with coordination of enrollment with service agencies.

17. Make reminder calls for patient visits, to include but not limited to the guidelines set forth by FHS for PCMH and Meaningful Use.

18. Participate in FHS meetings and committees as assigned.

19. Assist in planning of new strategies for outreach

20. Participate in outreach community events as needed.

21. Ability to travel to outreach and other FHS clinics.

22. Perform other duties as assigned.

Requirements:

OTHER RESPONSIBILITIES:

SAFETY:

Family Health Services enforces a safety culture whereby all employees have the responsibility for continuously developing and maintaining a safe working environment. Each employee is responsible for completing all training requirements, participating in emergency response tasks as requested, and serving on safety committees and teams as requested. In addition, employees must accept the responsibility for maintaining the safety of themselves and others by adhering to all written and verbal instructions, promptly reporting and/or correcting all hazards or unsafe conditions, and providing feedback to supervisors and management on all safety issues.

COMPLIANCE (MEDICARE):

Family Health Services is committed to the very highest standards of ethics and integrity. It is our policy to properly determine the accuracy of reporting and billing our services in accordance with the rules, laws and regulations of FHS, the state government, and the federal government. FHS employees will do their part to ensure accurate documenting and billing practices, participate in compliance trainings and will identify and report any concerns or activities that may violate these standards.

Each employee will be trained on the FHS Medicare Compliance Plan and the Standards of Conduct and asked to sign a Conflict of Interest Statement at hire and annually thereafter. A copy of the Medicare Compliance Plan and the FHS Standards of Conduct are available on the FHS home page under the Compliance tab.

PATIENT CENTERED MEDICAL HOME (PCMH):

Family Health Services is committed to providing our patients with the highest standards of care by becoming recognized as patient centered medical home. FHS staff is expected to participate in this process by being an active and willing PCMH team member. Specific duties and expectations may vary and will be identified by position and site.

PROCEDURE COMPLIANCE:

Employee must read and understand the general and specific operational, safety, and environmental requirements of all plans, procedures, and policies pertaining to this job.

WORKING CONDITIONS:

Work is normally performed in a typical interior/office work environment. No or very limited physical effort required. No or very limited exposure to physical risk.