Chronic Disease Care Coordinator (Serving Locations Across the NE Panhandle)

Important Information

The Chronic Disease Care Coordinator coordinates and delivers patient-centered care for individuals living with chronic health conditions. This is a remote position; however, applicants must reside in, or be willing to relocate to, the Panhandle of Nebraska.

Position Summary

All positions of PPHD will work to support the PPHD mission of "Working together to improve the health, safety, and quality of life for all who live, learn, work and play in the Panhandle." This position will support the implementation of PPHD strategic plan objectives through collaboration with partners and the community, a commitment to Community Health Improvement, dedication to implementing evidence-based practices, and implementation of the standards and measures of PHAB accreditation.

The Chronic Disease Care Coordinator coordinates and delivers patient-centered care for individuals living with chronic health conditions. This position focuses on patient education, disease self-management support, care coordination, and navigation of healthcare and behavioral health systems and community systems to support self-management, improve health outcomes, and reduce preventable complications and hospitalizations. The role works collaboratively with providers, interdisciplinary teams, and community resources to ensure continuity of care and access to needed services.

Essential Duties

The Chronic Disease Care Coordinator performs the following essential functions within the framework of Panhandle Public Health District’s provision of the core functions and essential services of public health: 

• Provide comprehensive education to patients and their families on chronic conditions, including medication management, lifestyle modifications, symptom monitoring, and self-management strategies.
• Work closely with physicians, providers, specialists, and interdisciplinary teams to coordinate care, including facilitating transitions (e.g., hospital to home) and ensuring continuity of services across providers and community resources.
• Promote and refer patients to evidence-based chronic disease programs and workshops.
• Develop individualized care plans that promote self-management and adherence to treatment(s).
• Monitor patient progress and adjust care plans and treatment as needed, in collaboration with treatment providers.
• Coordinate referrals to community health services and resources, including community health workers.
• Coordinate with facility discharge planning services to provide smooth transitions of care (e.g., hospital to home) to reduce hospital readmissions.
• Advocate for patients to ensure access to appropriate resources and services.
• Identify high-risk patients using data, clinical indicators, and referrals from healthcare partners.
• Support preventative care efforts and chronic disease screening programs.
• Utilize electronic health records according to organization-use agreements to maintain accurate and timely documentation of assigned patients to include the plan of care, treatment, medication management, lifestyle modifications, and referrals.
• Conduct ongoing assessments via in-person visits, telehealth, or phone follow-ups.
• Recognize early signs of disease exacerbations and intervene appropriately.
• Comply with all reporting requirements.
• Actively participate in Performance Management and Quality Improvement activities.
• Contribute to and participate in the implementation of the strategic plan as assigned.
• Contribute to development of program goals and objectives.
• Assumes responsibility for own professional growth and development by pursuing education, participating in professional committees and work groups and contributing to a work environment where continual improvements in practice are pursued.
• Performs other duties as assigned.
• Compliance with all PPHD personnel policies and procedures
• Follow and adhere to all HIPAA and PPHD and external provider’s confidentiality and privacy policies and practices.

Behavior Expectations

Treats others with courtesy and respect in all interactions and abides by PPHD’s Guiding Principles.

Minimum Qualifications

Unrestricted RN, licensed in Nebraska. Associates or Bachelor of Science in Nursing with 2 years’ experience. Prior experience in Chronic Disease Management, Patient Education, or Case Management preferred.

Ability to provide education to various levels of understanding, across all ages, and within culturally appropriate frameworks.

Valid driver’s license, current certificate of vehicle insurance, and access to reliable transportation to all assigned work locations.

Knowledge, Skills, and Abilities

This position will require the following knowledge, skills, and abilities:

• Apply the principles, practices and theories of public health assessment and planning to health promotion, policy development, and health improvement.
• Communicate effectively and work collaboratively with individuals and groups from a wide variety of backgrounds, interests and experiences.
• Excellent written, oral, and interpersonal communication skills.
• Delivery of services and education in a culturally sensitive manner.
• Effective presentation of data to address scientific, political, ethical, and social public health issues.
• Flexibility and the ability to manage time and multiple tasks with little supervision.
• The core functions and essential services of public health
• Program planning, implementation, and evaluation.
• National public health accreditation standards.
• Demonstrate ability to facilitate processes with diverse groups.
• Ability to use databases and spreadsheets, Outlook, internet searches.
• Understanding of public health competencies and how they relate to the work.
• Computer Skills.
• Patient education and motivational interviewing
• Care planning and coordination
• Critical thinking and strong clinical judgement

Work Environment

General office setting in the PPHD office sites, as well as community sites. Equipment used to perform functions is computer, fax, copier, personal or PPHD vehicle, and public health equipment and supplies. This job may encompass light lifting, standing, walking, being seated for periods of time, possible overtime, driving, some overnight travel, and infrequently working nights and weekends.