Chronic Disease Nurse Educator

The Chronic Disease Nurse Educator is a registered nurse who works collaboratively with primary care providers and the interdisciplinary care team to improve outcomes for patients with a focus diabetes and hypertension, but other chronic disease depending on health center need. The Nurse Educator sees patients referred by primary care providers and provides chronic disease education, monitoring, medication administration, and self-management support. Working under approved standing orders, protocols, and provider-directed plans of care, the Nurse Educator may order appropriate laboratory testing, titrate medication according to established algorithms, and communicate recommendations regarding medication management to the patient's primary care provider.

ESSENTIAL FUNCTIONS:

• Manage referrals from primary care providers for patients requiring additional education, monitoring, and support for chronic disease, including diabetes and hypertension.
• Provide individualized education regarding chronic diseases, including disease management, medications, nutrition, physical activity, treatment goals, and risk reduction.
• Teach patients to monitor health data, including but not limited to blood glucose and blood pressure at home, including proper technique, frequency, interpretation of results, and recognition of concerning values or symptoms.
• Review blood glucose logs, glucometer, continuous glucose monitoring data, home blood pressure readings, other data, medication adherence, symptoms, and other relevant clinical information.
• Educate patients regarding medication administration including but not limited to insulin and GLP-1 receptor agonists. This includes injection technique, dosing, storage, administration, and safe disposal; administer medications as ordered and within scope of practice.
• Titrate medications, including insulin according to approved algorithms, standing orders, or individualized provider-directed treatment plans and escalate patients who fall outside established parameters.
• Work collaboratively with primary care providers to support timely chronic disease medication management, including making recommendations regarding medication initiation or adjustment when provider action is required.
• Order laboratory testing and other monitoring studies authorized under approved standing orders or protocols and appropriately communicate or escalate abnormal findings.
• Document assessments, education, medication administration, interventions, recommendations, and follow-up plans accurately and timely in the electronic health record; participate in chronic disease quality improvement and population health initiatives.
• Collaborate with the interdisciplinary care team to address barriers to care and perform other related duties as assigned in support of patient care and organizational priorities.

REQUIRED KNOWLEDGE & SKILLS:

• Strong clinical knowledge of chronic disease including diabetes and hypertension, including disease management, medications, monitoring, complications, and patient self-management.
• Knowledge of chronic disease medications including but not limited to insulin, GLP-1 receptor agonists, antihypertensive medications, and associated monitoring requirements and common adverse effects.
• Ability to interpret medication data, including blood glucose trends, blood pressure measurements, laboratory results, and other relevant clinical information within the registered nurse's scope of practice.
• Ability to safely implement standing orders, clinical protocols, and medication-titration algorithms and recognize situations requiring provider consultation or escalation.
• Demonstrated ability to provide effective patient education using principles of health literacy, motivational interviewing, shared decision-making, and culturally responsive care.
• Strong verbal, written, and interpersonal communication skills with the ability to build trusting relationships with patients and families from diverse backgrounds.
• Ability to work independently while functioning effectively as a member of an interdisciplinary healthcare team.
• Strong organizational, time-management, clinical judgment, and problem-solving skills with the ability to manage longitudinal patient follow-up.
• Proficiency in accurate and timely electronic health record documentation while maintaining confidentiality and HIPAA compliance.
• Basic computer proficiency, including electronic health records and Microsoft Office applications.

REQUIRED EDUCATION & OTHER CREDENTIALS:

• Education: Graduate of an accredited school of nursing required. Bachelor of Science in Nursing (BSN) preferred.
• Licensure/Experience: Current, unrestricted Registered Nurse (RN) license in the Commonwealth of Massachusetts required. Two (2) years of registered nursing experience preferred; experience in primary care, ambulatory care, chronic disease management, diabetes education, care management, or community health strongly preferred.
• Certification/Competency: Certified Diabetes Care and Education Specialist (CDCES) certification preferred but not required. Demonstrated competency in blood pressure measurement, blood glucose monitoring, injectable medication administration, patient education, and implementation of clinical protocols and standing orders required.
• Software/Hardware: Proficiency with electronic health records and basic computer applications, with the ability to learn and utilize additional clinical and population health technology.