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Job description
Summary of Position
Deliver high-impact, population-based care management and diabetes education to high-risk members with diabetes. Integrate clinical care coordination, diabetes self-management education (DSME/Training), and medical nutrition guidance to improve outcomes, close care gaps, and support members across the continuum of care. Responsible for managing complex chronic conditions at scale, closing care gaps, and driving behavior change through structured outreach, coaching, and coordination. Engage members telephonically while also supporting virtual group diabetes education.
Principal Accountabilities
Manage a high-volume panel of complex, high-risk members enrolled in the A1chieve diabetes program.
Conduct comprehensive telephonic assessments (clinical, psychosocial, environmental, and financial) to identify member needs and gaps in care.
Develop, implement, and evaluate individualized care plans in collaboration with members, caregivers, providers, and interdisciplinary teams. Plans will be focused on A1c improvement and risk reduction.
Perform ongoing outreach, follow-ups, and engagement to ensure continuity of care.
Identify and close gaps in care (A1c monitoring, medication adherence, preventive screenings).
Coordinate services across providers, community resources, and internal teams to ensure safe, timely, and cost effective care.
Serve as primary clinical liaison and advocate for members across the care continuum.
Support transitions of care and complex case management initiatives.
Deliver diabetes self-management education (DSME/T) using ADCES7 clinical framework and evidence-based guidelines.
Provide individualized coaching, goal setting, and behavior change support using motivational interviewing.
Educate members on: insulin therapy, oral and injectable medications, continuous glucose monitoring, insulin pumps, and diabetes technologies, blood glucose monitoring and self-management decision-making.
Provide practical, culturally-competent nutrition counseling aligned with Standards of Care.
Support medication titration in collaboration with providers.
Teach carbohydrate counting and support insulin dose adjustments in collaboration with providers.
Facilitate virtual diabetes education classes and workshops for diabetic members.
Translate complex clinical concepts into clear, actionable education for diverse populations.
Promote peer engagement, accountability, and shared learning in group settings.
Support program goals for engagement and scalability through group education delivery.
Align members to internal and external resources to support whole-person care.
Contribute directly to program outcomes (A1c reduction, engagement, gap closure).
Execute A1chieve workflows for enrollment, panel management, outreach, and documentation.
Prioritize interventions based on risk stratification and program metrics.
Document all telephonic and virtual interactions in the EMR in a timely, compliant manner.
Ensure adherence to regulatory standards (ADCES requirements).
Monitor clinical outcomes and adjust interventions based on data and member progress.
Track member progress and adjust care plans based on clinical and engagement data.
Participate in case conferences, team huddles, and quality improvement initiatives.
Maintain industry level knowledge of trends, practices, digital design software, including high volume chronic disease and complex care management, diabetes self-management education & behavior change, motivational interviewing and patient engagement, interdisciplinary collaboration and care coordination, cultural competency and health equity focus, strong virtual communication and telehealth delivery skills.
Qualifications
Bachelor's degree
Active Registered Dietician Nutritionist license (NY required, compact preferred)
Certified Diabetes Care and Education Specialist (CDCES) required
4 - 6+ years relevant clinical experience, including 3+ years of diabetes care and/or care management (Required)
Experience in managed care, care coordination, or population health (Preferred)
Knowledge of diabetes treatments, insulin management, and technology (Required)
Experience and proficiency with telehealth and electronic medical records systems (Required)
Proficient in MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.) (Required)
Strong communication skills (verbal, written, presentation, interpersonal) with all types/levels of audiences (Required)
Ability to organize and prioritize and to manage simultaneous tasks; critical thinking skills (Required)
Willingness and ability to work 1+ evening/week as required to meet member needs (Required)
Additional Information
Requisition ID:
Hiring Range: $68,040-$118,800
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Who can apply
Review the original listing for work authorization, qualifications and employer requirements.