Chronic Disease Care Manager

Job Description

Job Description

Salary: $22-$27 Hourly

Organization: Vecinos, Inc.

Address: 19 Smoky Mountain Drive, Franklin, NC 28734

Phone: (828) 293-2274

Website:

Position: Chronic Disease Care Manger

Location: Franklin, NC and surrounding counties

Compensation: $22-$27 per hour

Benefits: Insurance, Retirement, Vacation

Classification: Non-exempt, permanent, full-time

Organization Description: Vecinos is a non-profit, 501(c)3 Free Clinic that provides bilingual integrated primary and mental health care, mobile clinic services, health education, and case management to uninsured, low-income adults in the far-western NC counties. We offer a positive, supportive, and team-oriented atmosphere. We work in a non-traditional environment with limited resources. Schedules and hours vary throughout the year.

Purpose: The Chronic Disease Care Manager is a clinical Community Health Worker (CHW) with a focus on chronic disease management, patient health education and goal-setting that enhances the quality of patients lives. The CHW III has advanced training in health education and community health worker certification with a focus on, and advanced knowledge of, Latino identity, language, and cultural expectations of healthcare systems.

Job Responsibilities:

1. Health Education
   1. Led by a Registered Nurse or medical provider, the Chronic Disease Case Manager partners with individual patients to create individualized care plans focused on chronic disease education, lifestyle management, and goal-setting that complement clinical care and enhance patient health outcomes.
   2. Maintain current trainings and knowledge of best practices for a variety of health education topics. Recommend relevant trainings and certifications to team leadership.
   3. Serve as the team lead in health education, providing in-depth health education within the appropriate scope of practice
2. Clinic and Outreach Support
   1. Collaborate with integrated care team members to manage a panel of chronic disease patients participating in the care plan program through regular encounters and follow-up focused on tracking progress of individualized care goals, health coaching and encouraging appropriate medical follow-up.
   2. Perform home visits and agricultural camp visits to provide individualized assistance to special needs cases.
   3. Participate in a high risk patient work group to coordinate seamless delivery of comprehensive care to support health and social well-being in patients with greatest need.
3. Administration

1. 1. Document all activity and communicate with the integrated care team on Vecinos electronic health record, AthenaNet; Manage patient cases, receive and send internal referrals, and other duties as needed.
   2. Complete required grant and electronic health record data tracking and entry.
   3. Complete regular analysis of the care plan program to demonstrate efficacy and areas for improvement.

Required Qualifications

• Bachelors degree in public health or related field
• At least two years experience in community health education and outreach with low-income, uninsured communities
• Native, or near-native English and Spanish fluency with excellent written and oral communication skills
• Demonstrated advance layman's knowledge of health education, demonstrated through certifications such as the Living Healthy with Chronic Diseases curriculum or ability to obtain certification(s)
• Strong computer skills with the ability to manage a variety of software and databases
• Strong organizational skills with the ability to work with a team and independently
• Valid drivers license and ability to drive large SUVs in a variety of settings
• Highly collaborative, flexible, and dynamic nature with strong communication skills
• Understanding of cultural competency and a desire to work with diverse people of all ages, without regard to sex, race, religion, or socioeconomic background

Preferred Qualifications

• Masters degree in public health or related field
• Certified Community Health Worker or related certification
• Willingness to work late nights and weekends and in nontraditional/non-clinical work environments across WNC
• Experience in medical interpretation
• Experience in an integrated care setting