Department: Rural Diabetes Management Program
Position: Diabetes Care Coordinator – LVN/RN
Schedule: Monday–Friday, 8:00 a.m.–5:00 p.m.
Status: Full-Time
Reports To: Administration/Program Leadership
Position Summary
The Diabetes Care Coordinator is a licensed LVN or RN responsible for coordinating patient care and supporting the implementation, monitoring, data collection, and reporting requirements of the organization's Rural Diabetes Management Program.
This position serves as a central point of coordination between patients, providers, clinic staff, nutrition services, Remote Patient Monitoring (RPM), Community Paramedicine, and other members of the interdisciplinary healthcare team. The coordinator will monitor patient progress, promote timely follow-up, maintain accurate program data, assist with required reporting, and help identify patients who may need additional intervention or support.
The ideal candidate is organized, detail-oriented, comfortable working with electronic health records and data, knowledgeable in clinical documentation and reporting, and able to communicate effectively with patients and healthcare professionals. This individual must also be flexible and willing to assist with direct patient care when needed.
Essential Duties and Responsibilities
Patient Care Coordination
• Coordinate care and follow-up for patients enrolled in the diabetes management program.
• Maintain an accurate registry of participating patients.
• Monitor scheduled clinic visits, laboratory testing, nutrition/diabetes education, RPM participation, and Community Paramedicine services.
• Contact patients regarding needed follow-up appointments, laboratory testing, education, monitoring, and other components of their care plan.
• Identify patients who have missed appointments, laboratory testing, education, or other recommended services and assist with re-engagement.
• Communicate patient needs, concerns, abnormal findings, and barriers to the appropriate provider or interdisciplinary team member.
• Assist patients in navigating available clinical and community resources.
• Identify barriers to successful diabetes management, including transportation, financial, access, education, and other patient-specific concerns.
• Promote continuity of care between the clinic, hospital, emergency department, Community Paramedicine, nutrition services, and RPM program.
Data Collection and Reporting
• Collect, enter, validate, and maintain accurate patient and program data.
• Monitor required clinical and program measures, including:
o Baseline and follow-up A1C values
o Change in A1C
o Baseline and follow-up DSMQ-R results
o Change in DSMQ-R scores
o Clinic follow-up dates and completion
o Nutrition/diabetes education participation
o RPM enrollment and participation
o Community Paramedicine visits
o Emergency department utilization
o Hospitalizations and readmissions
• Review patient records to ensure required data elements are complete and accurate.
• Maintain data in designated electronic health record reports, spreadsheets, databases, or other approved tracking systems.
• Assist with monthly, quarterly, annual, grant, quality-improvement, and DNP project reporting.
• Work with Information Technology, Quality, Administration, and other departments to identify data needs and improve reporting processes.
• Identify missing or inconsistent data and work with appropriate staff to correct documentation or reporting gaps.
• Assist with preparation of dashboards, summaries, and reports used to evaluate patient outcomes and program performance.
• Maintain confidentiality and protect patient information in accordance with HIPAA and organizational policies.
Diabetes Program Support
• Assist with enrollment and orientation of eligible patients into the diabetes management program.
• Reinforce diabetes education and provider-established plans of care within the LVN/RN scope of practice.
• Support patient engagement, medication/treatment adherence, appointment compliance, and self-management activities.
• Coordinate referrals to nutrition services, RPM, Community Paramedicine, providers, and other available resources.
• Participate in interdisciplinary meetings and program reviews.
• Assist with monitoring program goals, grant deliverables, quality measures, and patient outcomes.
• Support ongoing quality-improvement initiatives related to diabetes care and chronic disease management.
Clinical Support
• Maintain clinical competency appropriate to LVN/RN licensure and assigned duties.
• Assist clinic or hospital departments with patient care when needed and as directed by leadership.
• Perform nursing duties within the individual's scope of practice, competency, organizational policy, and applicable state regulations.
• Maintain flexibility to support organizational and patient-care needs while ensuring diabetes program responsibilities remain current.
Minimum Qualifications
• Current, unrestricted Texas LVN or RN license.
• Current BLS certification.
• Strong organizational and time-management skills.
• Strong attention to detail and accuracy.
• Ability to collect, organize, monitor, and report healthcare data.
• Proficiency with electronic health records and basic computer applications.
• Ability to learn and utilize reporting tools, spreadsheets, databases, and other electronic tracking systems.
• Effective written and verbal communication skills.
• Ability to communicate professionally with patients, families, providers, leadership, and interdisciplinary team members.
• Ability to independently manage multiple patients, deadlines, follow-up activities, and reporting requirements.
• Ability to maintain patient confidentiality and comply with HIPAA requirements.
Preferred Qualifications
• RN preferred; qualified LVN candidates will be considered.
• Previous experience in primary care, chronic disease management, diabetes care, case management, care coordination, population health, or quality improvement.
• Experience with electronic health record reporting and data collection.
• Experience with Microsoft Excel and preparation of reports or dashboards.
• Experience with Oracle Health/Cerner or similar electronic health record systems preferred.
• Experience with Remote Patient Monitoring, patient education, Community Paramedicine, or rural healthcare preferred.
• Knowledge of diabetes management and chronic disease care preferred.
• Experience working with grant-funded programs, quality measures, or healthcare performance reporting is beneficial.
Knowledge, Skills, and Abilities
The successful candidate should demonstrate the ability to:
• Develop strong relationships with patients and encourage continued participation in their care.
• Follow patients longitudinally and recognize when required care or follow-up has not occurred.
• Accurately collect and manage clinical and program data.
• Understand basic healthcare reporting and outcome measurement.
• Recognize trends, missing information, and opportunities for intervention.
• Work independently while collaborating effectively with an interdisciplinary team.
• Prioritize multiple responsibilities and meet reporting deadlines.
• Adapt to changing program and organizational needs.
• Provide compassionate, professional patient care.
• Learn new technology, reporting systems, and program requirements.
Work Schedule
Monday–Friday, 8:00 a.m.–5:00 p.m.
The position is primarily dedicated to diabetes care coordination, patient monitoring, data collection, and program reporting. Flexibility is required to assist with direct patient care and other clinical needs when necessary.
Position Goal
The goal of the Diabetes Care Coordinator is to ensure that patients enrolled in the diabetes management program do not fall through gaps in care. The coordinator will help ensure that patients receive appropriate follow-up, education, monitoring, and support while maintaining accurate data necessary to demonstrate improvements in clinical outcomes, patient engagement, and healthcare utilization.
BENEFITS:
Medical, Vision and Dental Plan
Group Life Insurance
Short Term and Long Term Disability
Retirement Plan
Personal Paid Time Off
Sick Pay
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