Chronic Disease Care Coordinator (Serving Locations Across the NE Panhandle)
Panhandle Public Health District·Gordon, Nebraska
Panhandle Public Health District·Gordon, Nebraska
Coordinates and delivers patient-centered care for individuals with chronic health conditions through education and self-management support. Collaborates with healthcare providers and community resources to ensure continuity of care and reduce hospital readmissions.
Important Information The Chronic Disease Care Coordinator coordinates and delivers patient-centered care for individuals living with chronic health conditions. This is a remote position; however, applicants must reside in, or be willing to relocate to, the Panhandle of Nebraska.
All positions of PPHD will work to support the PPHD mission of "Working together to improve the health, safety, and quality of life for all who live, learn, work and play in the Panhandle." This position will support the implementation of PPHD strategic plan objectives through collaboration with partners and the community, a commitment to Community Health Improvement, dedication to implementing evidence-based practices, and implementation of the standards and measures of PHAB accreditation. The Chronic Disease Care Coordinator coordinates and delivers patient-centered care for individuals living with chronic health conditions. This position focuses on patient education, disease self-management support, care coordination, and navigation of healthcare and behavioral health systems and community systems to support self-management, improve health outcomes, and reduce preventable complications and hospitalizations. The role works collaboratively with providers, interdisciplinary teams, and community resources to ensure continuity of care and access to needed services.
Essential Duties The Chronic Disease Care Coordinator performs the following essential functions within the framework of Panhandle Public Health District’s provision of the core functions and essential services of public health: Provide comprehensive education to patients and their families on chronic conditions, including medication management, lifestyle modifications, symptom monitoring, and self-management strategies.
Work closely with physicians, providers, specialists, and interdisciplinary teams to coordinate care, including facilitating transitions (e.g., hospital to home) and ensuring continuity of services across providers and community resources.
Promote and refer patients to evidence-based chronic disease programs and workshops.
Develop individualized care plans that promote self-management and adherence to treatment(s).
Monitor patient progress and adjust care plans and treatment as needed, in collaboration with treatment providers.
Coordinate referrals to community health services and resources, including community health workers.
Coordinate with facility discharge planning services to provide smooth transitions of care (e.g., hospital to home) to reduce hospital readmissions.
Advocate for patients to ensure access to appropriate resources and services.
Identify high-risk patients using data, clinical indicators, and referrals from healthcare partners.
Support preventative care efforts and chronic disease screening programs.
Utilize electronic health records according to organization-use agreements to maintain accurate and timely documentation of assigned patients to include the plan of care, treatment, medication management, lifestyle modifications, and referrals.
Conduct ongoing assessments via in-person visits, telehealth, or phone follow-ups.
Recognize early signs of disease exacerbations and intervene appropriately.
Comply with all reporting requirements.
Actively participate in Performance Management and Quality Improvement activities.
Contribute to and participate in the implementation of the strategic plan as assigned.
Contribute to development of program goals and objectives.
Assumes responsibility for own professional growth and development by pursuing education, participating in professional committees and work groups and contributing to a work environment where continual improvements in practice are pursued.
Performs other duties as assigned.
Compliance with all PPHD personnel policies and procedures Follow and adhere to all HIPAA and PPHD and external provider’s confidentiality and privacy policies and practices.
Behavior Expectations Treats others with courtesy and respect in all interactions and abides by PPHD’s Guiding Principles.
Unrestricted RN, licensed in Nebraska. Associates or Bachelor of Science in Nursing with 2 years’ experience. Prior experience in Chronic Disease Management, Patient Education, or Case Management preferred. Ability to provide education to various levels of understanding, across all ages, and within culturally appropriate frameworks. Valid driver’s license, current certificate of vehicle insurance, and access to reliable transportation to all assigned work locations.
Work Environment General office setting in the PPHD office sites, as well as community sites. Equipment used to perform functions is computer, fax, copier, personal or PPHD vehicle, and public health equipment and supplies. This job may encompass light lifting, standing, walking, being seated for periods of time, possible overtime, driving, some overnight travel, and infrequently working nights and weekends.
Requires an unrestricted RN license in Nebraska and an Associate or Bachelor of Science in Nursing with at least 2 years of experience. Must possess a valid driver's license and reliable transportation to serve the Nebraska Panhandle region.
Market context
In Nebraska, nursing support roles like medication aides and technicians are often driven by ongoing staffing needs in long-term care, assisted living, and similar settings. These jobs can be competitive because employers usually want a high school diploma plus current state-approved medication aide or technician certification, with insulin and CPR/BLS credentials preferred. Review the AI-summarized requirements and benefits here to save research time, and confirm your certifications are current before applying.
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