The purpose of the Program Team Leader - Diabetes is to oversee the management of the sub-population of members who are diagnosed with Diabetes, under auspices of the Chronic Care Improvement Program.
The Program Team Leader - Diabetes utilizes a chronic care management model while he/she plans, develops, assesses, and evaluates care provided to members with Diabetes in conjunction with PCP's, endocrinologists nursing staff, dietitians, social workers, case managers and outpatient diabetic education teams. The Program Team Leader provides direction and support to the Chronic Care Improvement Nurses responsible for the members under their care who are diagnosed with Diabetes. The Program Team Leader provides members, families and caregivers with resources necessary to better understand and self-manage his or her treatment. The Program Team Leader promotes continuity of care and assists the member sin overcoming barriers to care.
- Ensures the Chronic Care Nurses manage the members in the program per established guidelines, protocols and evidence-based practice guidelines (EPGs)
- Completes an annual assessmet of the Diabetes program/subpopulation within the greater context of the Chronic Care Improvemet Program; updates the program as needed based on the annual assessment
- completes an annual review and revision, when appropriate, of the Program Description and Evidence-based Guidelines
- Assists with the preparation of the Chronic Care Improvement Program submission to CMS
- Promotes member adherence to HEDIS/5 Star measures
- Assists in the development and implementation of new policies, procedures, processes and educational materials
- Maintains an appropriate caseload of members requiring Diabetes management
- In a telephonic model that engages members, families and/or caregivers, utilizes the nursing process to develop holistic, cost-effective, and individualized plans of care, ensuring high quality and continuity of care
- Develops relationships with diabetes education teams, endocrinologists and PCP's in support of the member's plan of care and ti improve coordination of care efforts
- Maintains current knowledge base in the aspects of the treatment of diabetes
- Facilitates referrals to appropriate in-network services and community resources
- Communicates updates to the member's team of health care providers, including his or her primary care and specialist physicians
- Identifies quality issues involving providers that adversely affect patient outcomes and submit to quality improvement department
- Participates in organizational and Regional team meetings to improve member outcomes and in keeping with established PH processes
- Promotes a professional positive image of PH throughout the community. Identifies and communicates community concerns and problems affecting PH to appropriate departments
- Reviews, evaluates and reports on PH statistical data
- Serves as a resource on Diabetes to PH staff
- Assists int he professional development and training of Chronic Care Improvement staff and other staff
- Participates in Senior health Series, Health Fairs and other Plan events as assigned
- Completes annual educational courses as required by PH
Diploma or degree in Nursing. BSN preferred. Current Louisiana license to practice and a minimum of 3 years experience within the last 5 years in the care of patients with diabetes. Knowledge of diabetes and current treatment modalities. Basic computer skills must include the ability to use e-mail and the ability to function in a Windows environment. Knowledge of chronic care management, utilization management,, managed care and Medicare preferred. Must have excellent communication skills both written and oral. Certified Diabetes Educator highly preferred.
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