Your new company

Hays are partnering with a National Healthcare provider who are looking for an experienced Chronic Disease Management Nurse to join their Fairfield team on a permanent basis.

Your new role

The Chronic Disease Nurse Manager is responsible for conducting patient-centered Chronic Disease Management and preventative health care services.
Key responsibilities of the role include:
• Prepare GP Management Plans with patients on behalf of the GP including: patient history and biometrics, chronic disease details, SMART goals for disease management, action plans and coaching on embedding health behaviour change principles
• Prepare Team Care Arrangements including: discussing benefits of ongoing care from multi-disciplinary teams, allocating allied health or specialist visits as appropriate and preparing referrals on behalf of the GP
• Conduct health assessments to assist in the early identification of the chronic disease, including: heart health assessment, 40-49 diabetes health assessment, 45-49 health assessment, 75+ health assessment, ATSI, Intellectual Disability, Veteran and Refugee health assessments
• Provide nurse monitoring and support to eligible patients as part of the GPMP, TCA or Health Assessment
• Identify appropriate services to patients and perform as required, including but not limited to: Electrocardiogram ECG, Ankle Brachial Index Test ABI, Spirometry, Domiciliary Medication Management Review DMMR and Urinalysis
• Coordinate care across the practice, together with GPs, specialists and allied health professionals to provide a holistic approach to care
• Ensure that care is carried out at a high quality and meets the clinical standards set by Medicare and ForHealth
• Understand Medicare rebates and requirements, billing accordingly
• Perform administrative tasks relating to carrying out consultations, ensuring compliance with Medicare
• Consult with the Regional Nurse Manager to review performance against KPIs and implement improvements
• Conduct business development activities to grow patient database and new patient appointments by: building relationships with GPs and promoting preventative healthcare throughout the practice to grow patient referrals
• Utilise available tools to identify eligible patients as part of proactive patient outreach
• Support the training of other Nurses in Care Plans, Team Care Arrangements and Health Assessments, and holistic approach to health promotion and disease prevention
• Support non-clinical staff un understanding CDM appointment requirements
• Ensure safe working practices, obligations and compliance is adhered to
• Report all incidents and hazards to management within 24 hours using the appropriate incident reporting procedures

What you'll need to succeed
• AHPRA Registered or Enrolled Nurse and 2+ years of experience in providing direct clinical nursing care preferred
• Prior experience in a primary health care setting preferred
• Experience with chronic disease management and familiarity with health promotion and disease prevention principles preferred
• Strong verbal and written communication skills with excellent time management
• Pass all quarterly clinical audits
• Increase referrals from GPs indicating quality patient care
• Engage in CDM community, peer-to-peer training and 1-1 mentoring
• Complete Litmos learning modules
• Attend regular training as part of ongoing upskilling
• Receive positive feedback from patients and from PNM/RNM on clinical performance
• Increase awareness of preventative health and disease management

What you need to do now

If you are interested in discussing this role in more detail, reach out to me now at alexandra.kennedy@hays.com.au or call me on 08 9254 4594.