Disease Management Nurse

Essential Functions: * 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 CHF and COPD. * Track and respond to patient referrals, meeting patients in-person and virtually to enroll in program. Instruct patients in use of self-monitoring equipment, medication adherence strategies, and lifestyle strategies for self-management * Manage onsite devices and relationship with DME vendor(s) 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 (stoplight tools, CDC Diabetes Prevention Program (DPP) curriculum, etc.) * 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 (inhalers, insulin syringes or pens, nebulizers, glucometers, CGMs) * 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 (i.e. refurbished nebulizers, loaner blood pressure monitors) for distribution to patients with insurance barriers to obtaining equipment * 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 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, 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