The Chronic Care Lead Nurse performs care management for chronically ill patients with chronic diseases such as chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, and/or congestive heart failure. The role involves collaboration and continuous partnership with chronically ill patients, their families/caregivers, clinic providers, and community resources to increase patients' ability for self-management and shared decision-making.
Key Responsibilities
Provide high-quality care that exceeds client expectations through a courteous, respectful, and compassionate manner.
Manage the registry of Chronic Care Management (CCM) for patients.
Validate enrollment of CCM patients based on provider requests.
Comply with documentation requirements of the CCM program by executing care plans and recording them in the Electronic Medical Records (EMR).
Monitor adherence to care plans, evaluate effectiveness, and facilitate changes as needed.
Determine the level of care coordination support required by patients and families.
Facilitate patient access to appropriate medical and specialty providers.
Coordinate transitions from inpatient to outpatient care to decrease readmission rates.
Work with in-office providers to manage symptom control, medication management, and provide education.
Educate patients and caregivers about relevant community resources.
Identify and enroll "high-risk" patients into the patient registry.
Coordinate continuity of care with external healthcare organizations and facilities.
Support patient self-management and behavior modification interventions.
Provide patient health counseling and instruction.
Qualifications and Experience
Graduate of an accredited nursing school as a Registered Nurse with a Diploma or Degree in Nursing.
Valid license with the Nursing Council of Kenya.
Updated Basic Life Support (BLS) and ACLS/ATLS certificates.
Minimum of 3 years' work experience in a healthcare setting involving patients with complex chronic disease states is preferred.
Skills and Competencies
Strong customer focus, empathy, and emotional intelligence.
Excellent interpersonal and communication skills.
Organizational awareness and high attention to detail.
Teamwork and results-oriented mindset.
Ethical and reliable professional conduct.
How to Apply
Interested and qualified candidates should apply online through the Avenue Healthcare career portal at careers.avenuehealthcare.com.
How to Apply
Interested and qualified candidates should apply online through the Avenue Healthcare career portal at careers.avenuehealthcare.com.
