Sanitas is a global healthcare organization expanding across United States. Our services include primary care, urgent care, nutrition, lab, diagnostic, health care education and resources for our patients. We strive to attract professionals who believe in our mission, vision and are dedicated to the service of our patients and their families creating a memorable experience through compassion, respect, and kindness.

Position Summary

This position is a Registered Nurse (RN) who performs work in coordination with the Care Programs leadership in an assigned geographical area and serves as a superuser role model for other nurses and unlicensed clinical staff. The Disease Management Program Lead RN supports and collaborates with operations team on care programs aspects. This role provides comprehensive Disease Management (DM) Services, applying and promoting self-management education, health promotion, wellness concepts and strategies to assigned patients with chronic and complex diseases, in addition leads by supervising, coaching, and mentoring their assigned care program group of staff. This position works with a multi-disciplinary team to assure the highest quality care while focused on the physiological, psychosocial and safety needs of each patient and their families.

Essential Job Functions

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Reports with Care Programs leadership
2. Complies with established corporate and departmental policies, procedures, objectives, quality assurance methods, and safety codes. Demonstrates compliance with licensing, regulatory and accrediting agency provisions as required.
3. Consistently demonstrates appropriate and professional communication behavior toward patients, customers, and coworkers. Cooperates with Management and peers to promote an environment of teamwork and collaboration.
4. Identifies candidates for disease management using the Innovaccer System Population Health Portal, Integrated ECW Database, and professional judgment in collaboration with the National Care Program Director and entire healthcare team
5. Perform, oversees, and coordinates the daily operations of the care programs at the centers; ensures work is complete and troubleshoots and resolves issues as they occur.
6. Assess all material or equipment needs by program.
7. Leads process improvement for team and serves as a liaison to leadership to ensure efficient patient flow and quality patient care. Provides input for coaching, training, counseling, and performance assessment processes.
8. Ensuring that all program staff know and understand the procedures for documenting patient education, and health records.
9. Holding a monthly program meeting, to promote communication and information sharing.
10. Conduct comprehensive assessment of patient/families with real or potential, acute and/or chronic health problems, which may include the psychosocial, cognitive, medical, and personal assets and limitations of the patient/family. Assess strengths, needs, and assets.
11. Work with multi-disciplinary team providing targeted disease management, education, and training services to a broad range of patients and their families with diverse needs.
12. Evaluate patient health risk assessments, disease knowledge to formulate a nursing care plan and conduct evaluation, monitoring on a regular basis and effect changes as needed.
13. Develop methods of tracking patient compliance to clinical guidelines and care plans
14. Perform direct and group patient education.
15. Preform patient follow up and monitoring according to patient health risk status as stated in program policy.
16. Promotes patient self-management of disease and behavior modification interventions.
17. Educates patient and family/caregiver(s) about relevant community resources.
18. Shares professional knowledge and learning with other team members.
19. Takes appropriate action to maintain a safe and aseptic environment.
20. Participate as a team member in the provision of medical and health care, interfacing with professional colleagues to provide comprehensive care. Is encouraged to participate on committees and attend required meetings, and in-services
21. Flexible to changes in work schedule and location as needed by organization.
22. Leadership Skills – Ability to influence others to perform their jobs effectively and to be responsible for making decisions.
23. Communicates and submit to the National Care Programs Director the performance biweekly program report status of their facility’s program productivity and paraprofessionals working with him/her.
24. Maintains effective and efficient use of equipment and supplies
25. Carry out other duties as assigned by the National Care Program Director
26. Attend and assist in company health fairs and events.

Supervisory Responsibilities

• Leads process improvement for team and serves as a liaison to leadership to ensure efficient patient flow and quality patient care. Assist with hiring, on-boarding, training, scheduling, mentoring and coaching disease management program Staff to success.

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.

While performing the duties of this job the employee is regularly required to work standing up, walk, use hands to operate tools and equipment and must be able to exert regularly up to 10 pounds of force, frequently exert 30 pounds of force and occasionally exert 50 pounds of force to constantly perform the essential job functions. The employee will be frequently required to reach with hands and arms, bend, balance, kneel, crouch, crawl, push, and pull. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus. The employee is subject to environmental conditions, protection from weather conditions but not necessarily from temperature changes. The worker is subject to noise; there may be sufficient noise to cause the worker to shout to be heard above ambient noise level.

Required Education and Experience

1. Experience in the development, planning, and evaluation of patient educational programs.
2. Must have passion for education, portray excellent listening skills, and knowledge of scope of practices.
3. Ability to multitask, analyze situations and respond appropriately.
4. Must possess the skills to work in a physically and mentally demanding environment.
5. Substantial interpersonal skills necessary to interact with patients, their families, and to
6. collaborate with health team members.
7. Must function with a high degree of autonomy and communication.
8. Must understand the healthcare continuum and have ability to solve complex problems.
9. Values consistent with culturally and family centered approach to care.
10. Maintain standards for professional nursing practice.
11. Must always be able to maintain patient confidentiality.
12. Must always have excellent oral and written communication skills in English and a second language.
13. Must demonstrate ability to work independently with patients while also as a team to achieve program goals.
14. Proficient software computer skills to include WORD, EXCEL and other Microsoft Office programs.
15. Must be detail-oriented to ensure accuracy of reports and data.
16. This position requires require some local travel to assist in covering other facility within the same area.

Preferred Education and Experience

1. Bachelor of Nursing preferred or Graduate from an accredited school of Nursing.
2. 2 years Disease Management experience preferred.
3. 2 years outpatient setting is preferred.
4. Experience with electronic medical records (EMR), eClinicalWorks is a plus.
5. Active and clear State Registered Nurse License
6. CPR-BLS Required; ACLS preferred.

This job description is not intended to be a complete list of all responsibilities, duties or skills required for the job and is subject to review and change at any time, with or without notice, in accordance with the needs of the company. Since no job description can detail all the duties and responsibilities that may be required from time to time in the performance of a job, duties and responsibilities that may be inherent in a job, reasonably required for its performance, or required due to the changing nature of the job shall also be considered part of the jobholder’s responsibility.