• Collaborates with supervisory physician to perform case management for diabetic patients and families.
• Participates in DM clinics providing education and coordination of services (such as periodic clinics that combine multiple screening activities and clinical care activities).
• Conducts comprehensive and focused assessments, including functional assessments of diabetic populations. 
• Identifies health problems by observation, interviews, and analysis of records.
• Works with the patient’s physician and the dietician to develop, plan, and coach patients towards lifestyle changes to optimize medical care for diabetes and all problems. 
• Maintains necessary records in the EHR, in the Diabetes Registry, and on customized data collection tools to establish priority analysis and evaluation for care.
• Provides on-going educational reinforcement as requested by medical staff. 
• Establishes mutually agreed-upon plans of care with patients.
• Performs screening tests as authorized and interprets findings to individuals or families.
• Consults with professional workers such as dietician and mental health staff. 

Skills: Case Management, Patient Education, Health Assessments, Team Collaboration, Data Analysis, Lifestyle Coaching, Diagnostic Screening, Care Planning

• Appropriately refers patients based on plan of care.
• Implements health coaching with an emphasis on disease prevention and health promotion to individuals and groups.
• Develops and secures culturally appropriate informational and educational materials, guides, brochures, etc.
• Collaborates with physicians and clinical staff to assess, plan and implement strategies to advance clinical practice and educational needs of patients and staff.
• Attends staff meetings, in-services and appropriate courses to maintain personal and professional growth.
• Participates in community activities, committees, workshops and seminars as assigned by the Medical Director.
• Maintains current practice guidelines for the clinic.
• Fosters teamwork demonstrates ability to communicate with and work with staff and other departments.
• Submits written reports and documentation of services to requested funding sources through the Medical Director and the SIHC Fiscal Department.
• Maintains patient confidentiality.

Skills: Patient Referral, Health Coaching, Material Development, Clinical Collaboration, Professional Development, Community Engagement, Practice Guidelines, Teamwork Communication

• Assess the patient's past history and current condition, establish and monitor the patient/family goals and outcomes
• Assess and implement patient/family education and home care needs
• Use an understanding of the principles of growth and development to assess patients age specific needs and age specific treatment.
• Specifically responsible for review and management of patient blood sugar levels, including application of the Continuous Glucose Monitoring System and insulin pumps.
• Plan and conduct patient education classes
• Informing patients of lab results, patient education tests such as training patients to administer medications at home, and administration of injectable medications in office
• Nutrition assessments and care plans contain data reflective of patients nutrition requirements relative to their age and medical condition.
• Drug/Nutrient Interactions are addressed and education is given, as appropriate.
• Communicates appropriate nutrition history and nutritional care in writing in patients medical records.
• Completes nutrition assessments and follows up in a timely manner as per policy and procedure. 
• Provide the highest quality service in an accurate, thorough and timely manner. 
• Maintains competency in nutrition therapy and demonstrates professional commitment and growth.

Skills: Patient Assessment, Education Implementation, Age-Specific Care, Diabetes Management, Nutrition Planning, Medication Training, Communication Skills, Quality Assurance

• Educate patients on food selection to maintain and promote health as well as to prevent and manage diabetes and associated comorbidities
• Train patients with diabetes on glucose monitoring and prescribed medication use
• Provide information and education to staff members including nutrition education
• Evaluate the dietary and lifestyle needs of the patient, collaborate with the patient to develop and implement a plan, and document all pertinent information in the patient’s electronic medical record.
• Provide information and education to staff members using nutrition education materials or in-service meetings per request
• May implement and monitor quality control programs
• May participate in or manage special projects/programs, as needed
• Educate patients on diabetes self-management (including pathophysiology, medications, monitoring, nutrition, physical activity, acute complications, chronic complications, psychosocial support, and goal setting and ongoing resources).
• Educate patients on continuous glucose monitors and insulin pumps.
• Assist with professional continuous glucose monitors.
• Assist patients in obtaining supplies.
• Educate patients in the clinic and virtually.
• Educate patients using the diabetic program in compliance with the American Diabetic Association guidelines.
• Document all patient interactions in the EMR.
• Assist in developing educational material.

Skills: Patient Education, Glucose Training, Staff Training, Dietary Evaluation, Quality Control, Project Management, Virtual Consultation, Documentation Skills

• Design and deliver diabetes management education and services for people within a defined population. 
• Patients may be seen in a clinic office, inpatient or community setting according to the scope of practice, standards of practice, and standards of professional performance
• Facilitates the attainment and maintenance of optimal level of health for individuals with diabetes by collaborating with other health care members to develop the diabetes plan of care. 
• Provide diabetes self-management education and diabetes management recommendations to patients and families in the in-patient and out-patient settings
• Provide education / management to patients with all types of diabetes
• Assess and develop a plan of care, evaluate effectiveness of plan
• Works closely with the entire medical staff and nursing staff to prepare patients for discharge in a safe, efficient manner
• Provides tools and skills for home care to patients and families. 
• Makes recommendations to hospital staff for changes in diabetes management
• Serves as an educational and informational resource to all hospital staff and the community.
• Collaborate with medical, nursing, and case management staff
• Remain current on the rapidly changing field of diabetes management and the latest recommendation for patient education techniques
• Teach all aspects of insulin management

Skills: Diabetes Education, Collaborative Care, Self-Management Training, Care Planning, Discharge Preparation, Home Care Guidance, Staff Resource, Insulin Management

• Prior work experience in a healthcare environment.
• Certification in continuing professional education of diabetes self-management education and support
• Experience in Subcutaneous Continuous Insulin Infusion (insulin pumps)- education for initiation, titration, and troubleshooting.
• Experience with continuous glucose monitoring
• Experience with treatment and management of Type1, Type2 and gestational Diabetes.
• Must hold a valid License as a registered Nurse in the state of NJ
• Certification in continuing professional education of diabetes self-management education and support
• Board Certified Diabetic Educator by the National Certification Board of Diabetic Educators(NCDBE) Certified as an Adult Nurse Practitioner by the American Nurses Credentialing Center (ANCC)
• Excellent attention to detail.
• Excellent verbal and written communication skills

Qualifications: BS in Nursing with 4 years of Experience

• Experience in the area of diabetes management
• Academic and/or experiential preparation in program management and in the care of people with chronic disease.
• Demonstrated competence in teaching and in applying principles of teaching/learning processes.
• Demonstrated competence in skills of communicating, leadership and creativity with groups.
• Demonstrated ability and/or willingness to develop skills in teaching and in applying principles of the teaching/learning process with adult learners and child learners.
• Experience in insulin pump therapy or willingness to learn all aspects of insulin pump therapy to become a certified pump trainer.
• Microsoft Office computer skills required, including Word, Access and Excel.
• Excellent interpersonal skills and ability to effectively deal with all levels within the organization and community.
• Successful completion of annual clinical, age specific and job specific competencies and skill validation tools.

Qualifications: BS in Nutrition and Dietetics with 3 years of Experience

• Registered Dietitian (RD) required with current certification by CDR, Certified Diabetes Care and Education Specialist 
• Must have state licensure if residing in state that requires licensure
• Patient-centric, positive and upbeat attitude to be a cheerleader for the consumer
• Motivational Interviewing skills
• Strong written and verbal skills
• Comfortable working remotely and independently, a real self-started extremely strong relationship building skills
• Open-minded, compassionate, and non-judgmental
• Flexibility in working with a wide range of individuals across different communication mediums (text/voice/email)
• Critical thinking and tech-savvy, ability to solve problems within multiple computer applications. 
• Ability to learn a new software quickly.
• Proficient with cloud-based applications such as Google Drive, CRM’s (Salesforce), and other technological systems

Qualifications: BS in Pharmacy with 2 years of Experience

• Knowledge of patient education/training practices and theories.
• Knowledge of formulating education/training goals and objectives consistent with patient needs. 
• Knowledge of instructional skills and learning theory, educational. Knowledge of Nutritional sciences and insulin dependency. 
• Ability to develop health education programs and instructing patients/families in managing diabetes.
• Ability to analyze patient education needs and recommending programs to meet needs and in convey patient education concepts to other staff. 
• Ability to exercise initiative, judgement, and decision-making in meeting plan of care objectives.
• Ability to work effectively as part of a healthcare team.
• Ability to creatively problem-solve.
• Ability to provide reliable transportation to and from satellite clinics.

Qualifications: BS in Public Health with 3 years of Experience

• Diabetes self-management education and support experience.
• Excellent verbal and written communication skills.
• Basic computer skills including use of Microsoft Office.
• Has working knowledge of diabetes technology.
• Highly organized and with strong attention to detail.
• Strong problem solving and critical thinking skills.
• Must be able to work with a diverse patient population and have exceptional customer service skills.
• General knowledge of nutrient analysis, word processing and spreadsheet software
• Demonstrated knowledge of adult learning theory.

Qualifications: BS in Health Education with 2 years of Experience