Job Description

The Diabetes Care Management Program Coordinator (RN) functions in the role of a Diabetic Case Manager within the Community Health Services Department and serves as the coordinator for the organization's Diabetes Care Management Program. This position is responsible for providing comprehensive case management services to patients diagnosed with diabetes and related chronic conditions while leading program coordination activities designed to improve clinical outcomes, close care gaps, enhance patient engagement, and support quality, population health, and value-based care initiatives.

The RN collaborates with providers, care teams, patients, families, and community partners to ensure the delivery of evidence-based diabetes care. The position serves as the primary clinical resource for diabetes care management and is responsible for monitoring program performance, coordinating interventions, and supporting organizational goals related to chronic disease management, health equity, and community health improvement.

The duties of the position include

• Conduct comprehensive assessments of patients with diabetes and related chronic conditions - Assess each patient's medical history, current health status, medication adherence, diabetes self-management knowledge, lifestyle behaviors, nutritional needs, behavioral health concerns, barriers to care, and readiness for change. Evaluate risk factors that may impact health outcomes and utilize assessment findings to develop individualized, patient-centered care management plans that support improved glycemic control, chronic disease management, and overall health outcomes.
• Develop, implement, and monitor individualized care plans.
• Coordinate care across primary care, specialty care, pharmacy, behavioral health, and community resources.
• Provide comprehensive, individualized diabetes self-management education to patients, including instruction on disease progression, medication management and adherence, insulin administration (when applicable), blood glucose monitoring and interpretation, physical activity, weight management, and lifestyle modifications. Educate patients on recognizing and managing the signs and symptoms of hypo- and hyperglycemia, preventing diabetes-related complications, proper foot care, and the importance of routine preventive screenings, follow-up appointments, and medication compliance. Reinforce self-management skills using evidence-based education and motivational interviewing techniques to improve patient engagement, self-efficacy, glycemic control, and overall health outcomes.
• Identify and address barriers to care, including social determinants of health, transportation, financial concerns, and health literacy challenges.
• Conduct proactive patient outreach and follow-up through phone calls, telehealth, patient portal messaging, and other communication methods to promote engagement, reinforce the plan of care, monitor progress, address barriers to care, and encourage adherence to treatment plans, medications, follow-up appointments, and recommended diabetes self-management activities. Reassess patient needs and coordinate appropriate interventions to improve clinical outcomes and reduce gaps in care.
• Serve as the coordinator and clinical lead for the Diabetes Care Management Program.
• Develop, implement, and maintain program workflows, policies, and procedures.
• Monitor program outcomes and key performance indicators, including A1C control, retinal eye exams, nephropathy screening, blood pressure control, foot exams, and medication adherence.
• Maintain and manage diabetes patient registries and population health reports.
• Coordinate interdisciplinary team meetings focused on diabetes care improvement.
• Prepare and present program performance reports to leadership and quality committees.
• Lead diabetes-focused quality improvement initiatives.
• Support compliance with UDS, HEDIS, CMS, NCQA, and other quality reporting requirements.
• Coordinate diabetes education programs, support groups, and community outreach activities.
• Serve as a subject matter expert and resource for diabetes management throughout the organization.
• Collaborate with internal and external stakeholders to improve access to diabetes-related services and resources.

Education, Experience, and Skills

• Associate’s or Bachelor’s degree in nursing from an accredited program
• Must be licensed to practice as a registered nurse in the state of South Carolina
• Experience in diabetes education is strongly preferred
• Experience in medical case management is strongly preferred
• A minimum of two years’ experience is strongly preferred
• BLS certification by the American Heart Association or the American Red Cross is required
• Must have the skills to demonstrate expertise in diabetes and related chronic conditions.
• Must be able to teach diabetes self-management using evidence-based practices and adjust education to patient needs.
• Must have the ability to use behavior change techniques to improve outcomes and support patient self-efficacy.
• Must have the ability to organize workflows, monitor program performance, and coordinate organizational initiatives.
• Must have the ability to coordinate services among providers, specialists, behavioral health, pharmacy, and community resources.

Location

The primary work location is Society Hill but will be required to work at all CareSouth locations and across the Pee Dee Region of South Carolina in the counties of Lee, Darlington, Chesterfield, Marlboro, and Dillon.

Hours

Monday - Friday; 8:00 AM – 5:00 PM

CareSouth Carolina is committed to providing equal employment opportunities to all. We seek to have a diverse, inclusive workforce and encourage applications from all qualified individuals without regard to race, color, age, sex, gender identity or expression, sexual orientation, religion, marital status, citizenship, disability, or veteran status.