HealthCore Clinic

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Chronic Care Coordinator  (Full Time)
Department:: Medical



At HealthCore Clinic, we pride ourselves on being a premier medical employer and learning institution for individuals willing to serve the underinsured.  Our “You-Centered” approach to healthcare for our clients only works because we employ, train and retain the best of the best.

At Healthcore Clinic, we believe healthcare is a human right whose access should not be bound by finances.  If you believe in our philosophy and are fun loving, open minded, caring and flexible with your schedule, then you have come to the right place.  We are people serving people, serving people.  We are looking for a dynamic individual to join our family at Healthcore Clinic.


Job Purpose: The Chronic Care Manager possesses clinical expertise in care related to diabetes management and other chronic diseases.


Patient-Centered Medical Home Essential Functions:

Additional Essential Functions include the following.

1. Provide outpatient diabetes and self-management training and education to type 1, type2, and gestational diabetic patients. Education includes, but is not limited to, signs/symptoms and respective treatments for hyperglycemia, hypoglycemia, DKA, HHNK, and sick day therapies. 

2. Plan, develop, and implement individual and group diabetes education for adults, pediatrics, and their families and caregivers. 

3. Instruct patients in the Standards of Care for diabetes. 

4. Provide nutritional counseling for weight control and disease management. 

5. Deliver patient education as needed or as directed by the Provider. 

6. Perform assessments and data collections, establishes outcome criteria; obtains, reviews, and analyzes information in collaboration with patients, family members, and health care team members. 

7. Develop collaborative relationships with other departments, services, and community health care agencies to facilitate and support quality diabetes care. 

8. Attend outreach activities such as health fairs for diabetes screening and health education. 

9. Evaluate the diabetes and health education program on a continuing basis; assesses teaching methods and education material for both staff and families of patients. 

10. Monitor and evaluate short and long-term patient responses to therapeutic interventions in collaboration with providers; provides and maintains necessary follow-up for patients and families. 

11. Educate and follow patients with diabetes for control of blood sugar, lipids, renal function and prevention of diabetes complications. 

13. Instruct patients and family members on how to administer insulin, self-monitor blood glucose, and medication education. 

14. Perform all other related duties as assigned or requested.


Qualifications and Requirements:

·        Professional knowledge and skill as a diabetes and health educator

·        Ability to investigate and analyze information and to draw conclusions

·        In-depth knowledge and understanding of the nature of diabetes and related issues and patient care concerns

·        Ability to design, develop, deliver, and evaluate educational programs and materials

·        Ability to work and interact with patient care professionals as part of an interdisciplinary team

·         Ability to provide technical advice, guidance, and support to professional staff in are of specialty

·        Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community


Education and Experience (Required):

·        High school diploma or equivalency

·        3-5 years’ experience working with the Diabetic population

·        LPN or experienced Medical Assistant

Education and Experience (Preferred)

·        High School diploma or equivalency

·        Bachelor of Science in Nursing

·        LPN

·        Experienced MA

·        Certified Chronic Care Manager


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