Endocrine Nurse Care Manager - Harwich, United States - Outer Cape Health Services

Mark Lane

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Mark Lane

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Description

Registered Nurse - Endocrine Nurse Care Manager

Required to travel to all three locations

Our Culture:
Why work with us?


Joining Outer Cape Health Services isn't just about taking on a new role; it's about embracing a mission that goes beyond the day-to-day.

Here, you become part of a dedicated team committed to safeguarding and nurturing invaluable community health resources.

Our ethos is built on creating a vibrant and inclusive workplace where every team member is valued and recognized for their unique contributions.


Who We Are:


Our mission is to provide a full range of primary health care and supportive social services that promote the health and well-being of all who live in or visit the ten outermost towns of Cape Cod.


OCHS now cares for more than 18,000 patients annually, and no one is denied access to services due to an inability to pay.

Founded in 1987 through the merger of Health Associates of Provincetown (established in 1972) and the AIM Medical Center in Wellfleet (established in 1966), Outer Cape Health has a long history of successful growth and expansion in pursuit of this mission.

As a Patient-Centered Medical Home, OCHS holds itself to the highest standards.

Ensuring patients have access to care when they need it and request it, and validating that staff are working at the top of their licensures, are foundations of this model.


Our Core Competencies:


At Outer Cape Health Services, our core competencies are the foundation upon which our organization is built, guiding us in our mission to deliver exceptional health services to our communities.

Our focus on fostering teamwork ensures that we operate as a cohesive unit, valuing each member's contribution and working synergistically towards common goals.

Integrity and honesty stand at the heart of everything we do, creating a culture of trust and respect among our team and the communities we serve.

Embracing technology, we continually seek innovative solutions to enhance our services and operations.

Finally, being patient-centered, we prioritize the needs and well-being of those we serve, striving to exceed expectations and make a meaningful difference in their lives.


A day in the life of this role:

The Endocrine Nurse Care Manager at Outer Cape Health Service ("OCHS") is responsible for providing care management for our patients/families with Type 1 diabetes mellitus.

Under the supervision of a licensed endocrinologist, the nurse care manager is responsible for all aspects of quality care related to diabetes and will stay in close communication with our patients and families based on their needs or work directed by the provider and evidenced -based care best practices.

The Endocrine Nurse Care Manager will schedule appointments, manage calls, order lab studies under the direction of the endocrinologist, review results, facilitate remote monitoring, follow up with patients, manage specialist referrals, educate on medication administration and adherence, and provide chronic disease management.


Summary of duties:


  • Supports achievement of patient and population targeted outcomes, advising on diabetes program development as appropriate.
  • Elevates skills and knowledge of internal teammates and departments who also provide care to patients with diabetes and acts as a resource.
  • Outreaches to and manages a caseload of patients identified through referrals/consults and/or population stratification algorithms per department expectations.
  • Interacts with patients primarily through inperson visits as well as telephonic and/or virtual means.
  • Executes nursing process that starts with assessing whole person needs which influence patient outcomes, including (but not limited to): social determinants of health (SDOH), medication use/adherence, selfmanagement knowledge/skills/abilities, patientcentered goals, and physical symptoms.
  • Utilizes clinical expertise, American Diabetes Association (ADA) standards, and evidencebased practice to identify and analyze complex problems in nursing care of individuals and populations with diabetes; makes recommendations, evaluates alternative solutions, and followsup with appropriate health care personnel and patients.
  • May adjust diabetes medications from physicianprescribed starting dosage per protocol (with appropriate training/competence and physician approval) and evaluate effects.
  • Advocates for patients and professionally communicates with leaders and interprofessional teams to create a patientcentered plan of care to support optimal patient and population wellbeing.
  • Uses approved technology to interact with patients with diabetes, their equipment, and related data. Technology utilized includes (but is not limited to): soft phone, glucometer, continuous glucose monitor, insulin pump, glucometer data platforms, remote patient monitoring, and video visit software.
  • Executes workflows within the OCHIN EPIC electronic medical record and related patientcare platf

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