CHRONIC CARE MANAGER
The William F. Ryan Community Health Network is a group of not-for-profit, federally qualified health
centers that delivers high quality, affordable and comprehensive medical care to diverse and
underserved communities. We are currently seeking Chronic Care Managers for several Ryan Center
locations in Manhattan.
Position Overview:
Provide individualized diabetes self-management education/ training to individuals and groups
according to the Scope of Practice, Standards of Practice, and Standards of Professional performance for
Certified Diabetes Educator. This work is carried out in support of the mission and goals of Ryan
Network.
Essential Functions:
 Design an operational model for administering the office or telephonic based chronic care
program.
 Implement a program to ensure that patient assessment, risk satisfaction, education, referrals,
and longitudinal management of patients is completed in accordance with departmental and
NCQA standards.
 Supervise and direct each member of the Chronic Care team to ensure they are evaluating and
managing patients according to departmental standards.
 Provide health coaching and support to at-risk diabetic patients via face-to-face and telephone
encounters.
 Collaboratively develop educational goals, learning objectives and a plan for educational content
and teaching methods with DSME/T program participants.
 Participates in the development of training materials.
 Provide educational interventions that utilize primarily interactive, collaborative, skill-based
training methods, and maximize the use of interactive training methods.
 Organize, develop, and facilitate diabetes education group meetings.
 Deliver individualized diabetes education, including but not limited to the evaluation of each
patient’s condition, degree of control and educational needs, as well as ensure progression of
the care management plan and promote achievement of established goals.
 Evaluate effectiveness of educational services provided by measuring attainment of learning
objectives.
 Collect DSME/T program participant assessment data.
 Document assessment data, educational plan, educational services provided and evaluation
results in each participant’s educational records.
 Collaboratively develop an individualized follow-up plan with each program participant.
 Conduct a follow-up assessment upon completion of DSME/T program services using outcome
measures.
 Inform the PCP of the needs of the patients, and institute changes in pharmacologic regimens as
per PCP instructions.
 Act as a resource to patients and PCPs in enabling patient access to the PCP or presenting
information to the PCP for medical decision-making.
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Determine when a program participant’s needs are outside the scope of the instructor’s practice
and expertise, and arrange for additional services to meet needs.
Connect patients with identified clinical staff or resource needs to other enabling staff.
members, such as Navigators, Care Manager RNs, Health Home staff, and Licensed Clinical Social
Workers.
Contributes to, and participates in, a continuous quality improvement process to measure
DSME/T program and to identify and address opportunities for improvement.
Appraises his/her performance to identify areas of strength and areas for improvement and to
develop a plan for improvement and growth.
Participates in peer review process to evaluate performance of other professional instructional
staff.
Projects and/or other duties as assigned.
Minimum Experience and Skills Required:
 6+ months of experience providing diabetes education and/or 15 contact hours within past year
in diabetes and diabetes clinical and educational subjects.
 Working Knowledge of disease and case management principles and practices.
 Ability to develop a collaborative, therapeutic alliance with individuals.
 Ability to lead and effectively manage groups.
 Comfortable providing education to patients individually and in a group setting, and working
collaboratively with the care team.
 Computer literate in a Windows environment.
Education, Licenses and/or Certification Required:
 Bachelor of Science (BS)
 Currently licensed and registered in the State of New York, Registered Nurse, Certified Nurse
Specialist, Nurse Practitioner, Physician’s Assistant, or Pharmacist
Preferred Qualifications:
 Master of Science (MS)
 Certified Diabetes Educator (CDE)
 Doctor of Pharmacy (Pharm D)
 Experience with children with type 2 diabetes highly preferred
 Experience with electronic medical records, specifically eClinicalWorks
Competencies Required:
Customer Service:
 Professional, courteous and respectful attitude in dealing with patients
 Commits to exceeding expectations of the patient
Cooperation/Teamwork
 Works well with others
 Contributes input to improve outcomes
 Asks others for opinions and feedback; provides feedback in a tactful respectful way
Minimal Training Time:
Probationary period consisting of three months of actual work days.
Working Conditions:
Physical Demands
The physical demands described here are representative of those that must be met by an employee to
successfully perform the essential functions of this job. Reasonable accommodations may be made to
enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is frequently required to sit, talk and hear.
Specific vision abilities required by this job include close vision and the ability to adjust focus.
Work Environment
The work environment characteristics described here are representative of those an employee
encounters while performing the essential functions of this job. Reasonable accommodations may be
made to enable individuals with disabilities to perform the essential functions.
The work is primarily in a mental health and/or general primary care setting which include the
unpredictability in behaviors of individuals and acute and chronic infectious diseases which may
be contagious. Adequate preparation and precaution is necessary.
Disclaimer
The duties listed above are intended only as illustrations of the various types of work that may be
performed. The omission of specific statements of duties does not exclude them from the position if the
work is similar, related or a logical assignment to the position. This position may be required to perform
other duties. If such work becomes a permanent and regular part of the job, a new description will be
prepared.
Please forward resume and salary requirements to [email protected], and reference job
title in the subject line.
Equal Opportunity Employer
Ryan Network is an Equal Opportunity / Affirmative Action Employer and does not discriminate because
of age, color, disability, ethnicity, marital or family status, national origin, gender identity, race, religion,
sex, sexual orientation, military veteran status, or any other characteristic protected by law. We are
committed to attracting, retaining and maximizing the performance of a diverse and inclusive workforce.
Approved By (Name & Title): ________________________________
Signature:___________________________________
Date:_______________________________________
Revised: August 2016