Chronic Disease Care Manager

The Chronic Disease Care Manager is responsible for managing and delivering the One Year to a Healthier You (OYHY) program—an integrated, community-based chronic disease and cancer prevention initiative targeting patients with or at risk for diabetes, hypertension, obesity, and related health concerns. This role combines care coordination, health education, nutrition support, and community outreach to improve health outcomes and promote sustainable behavior change among program participants.
This position will serve as the primary point of contact for referred patients, oversee intake and follow-up, deliver group and individual education sessions, and collaborate with TAN clinical staff, behavioral health, and external partners such as Market to Hope.

Essential Job Responsibilities:
Patient Engagement & Coordination
• Receive and process patient referrals from TAN providers and LVNs
• Conduct comprehensive intake assessments, including social determinants of health
• Develop individualized care plans focused on lifestyle modification
• Coordinate care across TAN departments (e.g., primary care, behavioral health)
Program Delivery & Education
• Lead individual and group health education sessions on:
• Healthy eating and the CDC Healthy Plate model
• Portion control and food label reading
• Sodium reduction and cancer prevention
• Physical activity strategies and behavior change techniques
• Track patient progress, including biometric data and session participation
• Provide regular follow-up, motivation, and accountability to program participants
• Facilitate patient understanding and use of Remote Patient Monitoring (RPM) tools
Community Collaboration & Outreach
• Partner with Market to Hope to coordinate food box distribution and community screenings
• Support education of MtH staff and volunteers through training sessions and video materials
• Participate in outreach events and assist with promotion of the OYHY program
Documentation & Reporting
• Maintain accurate and timely documentation in the Electronic Health Record (EHR)
• Submit monthly reports detailing patient engagement, outcomes, and service delivery
• Assist in grant compliance, outcome tracking, and quality improvement efforts
• Perform other duties as assigned.

Minimum Education, Qualifications and Experience:
• Bachelor’s degree in Nutrition, Health Education, Public Health, or a related field
• Minimum of 2 years’ experience in chronic disease management, health education, or care coordination
• Strong understanding of social determinants of health and health disparities
• Experience facilitating group education or wellness classes
• Excellent interpersonal, organizational, and communication skills
• Proficient in Microsoft Office and comfortable with EHR documentation

Preferred:
• Certified Health Coach, CHES, or Registered Dietitian credentials
• Bilingual (Spanish/English) strongly preferred
• Familiarity with Southeast Texas community resources and population health needs

Work Environment & Physical Requirements:
• Hybrid office and field-based role
• Must be able to sit, stand, and walk for extended periods
• Requires local travel to food pantry locations, community events, and TAN clinics