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Care Manager, McLeod Family Medicine Center

Florence, SC


  1. Maintains a professional image and exhibits excellent customer relations to patients, visitors, physicians, and co-workers in accordance with our Service Excellence Standards and Core Values.
  2. Under the direction of the McLeod Family Medicine Residency Total Team Care Duke Endowment Grant (2021-2023), the Nurse Navigator will serve as Team Leader to identify eligible patients and referrals with a focus on diabetes education and self-management practices and diabetes standards of care. The Nurse Navigator is responsible for fulfilling the mission of the TTC concept and funded grant and assisting patients and families with new or ongoing chronic health conditions with a focus on diabetes comprehensive management including a collaborative team approach to maximize overall patient care experience and outcomes.. Strategies include the following:
  3. The Navigator will serve as the first point of contact for referral of patients and collaboration of the TTC approach to providers, McLeod Outpatient Diabetes Center, and family medicine residents, attending physicians, or other key integrated care partners.
  4. The Navigator will monitor admissions/readmissions, missed appointments with designated metric reporting and coordinate The Navigator will monitor admissions/readmissions, missed appointments, ED visits and hospitalizations with designated metric reporting and coordinate with the with FMC Quality Coordinator to report statistics monthly and quarterly. The Navigator will also track quality metrics pertinent to enrolled patients with diabetes including A1C levels, patients with A1C >9%, annual depression screenings and follow up to demonstrate depression remission, annual oral health exam and referral to dentist, and annual wellness visits for enrolled patients. The Navigator will coordinate with Oral Health, Behavioral Health and Pharmacy services to ensure that the patient’s and family’s whole needs are met to reduce and prevent unnecessary ED visits and hospitalizations and improve quality of care overall for Family Medicine Center patients with diabetes.
  5. The Chronic Care Navigator/Diabetes Care Manager in collaboration with the health care team (TTC) is responsible for the overall administration of the TTC program and specific services for patients enrolled in TTC. The CCN manages identified patients through routine telephonic and/or electronic communication based on needs identified through the collaborative TTC team and referrals through the McLeod Family Residency Program. The CCN will demonstrate performance consistent with professional standards of practice and consistent with ADA (American Diabetes Association) standards of practice.
  6. Directs implementation of TTC program including collaboration of services to meet the needs of the patients.
  7. Identify and navigate patients through the program specific screens, enrollment, and follow up processes.
  8. Assists in transition from episodic to comprehensive team-based care with quality outcomes as measures of success.
  9. Develops dashboards for forecasting and reporting department strategic goals with FMC Quality Coordinator. Takes ownership of data collection and analytics on quality queries.
  10. Offer information and referral to collaborative team members.
  11. Follow up with members concerning any missed appointments and assist with rescheduling.
  12. Identify and collaborate with integrated team members to facilitate patient care and reduce risks of missed appointments or issues encountered during the process.
  13. Implement referrals that serve to reduce barriers and increase opportunities to achieve optimal health care using total team care concept.
  14. Participate in the assessment, referral, educational plan, counseling, procurement of services pertaining to diabetes education and self-management for outreach to patients in Florence and surrounding counties under the supervision of the Director of CCM/Diabetes Center.
  15. Contribute to patient-centered care plans using interdisciplinary approached methods to care to meet individual needs of each patient.
  16. Inform FMC and community providers, patients and families of services within the TTC that will promote overall quality health of those members served having diabetes.
  17. Schedule routine collaboration meetings with TTC providers to maintain current communication and analysis of process/methodologies.
  18. Place phone calls, conduct risk assessments, perform follow up with patients according to guidelines of the program.
  19. Work with patients to enter in TTC and receive access to team care that will promote reduction of barriers in transportation, language, lack of insurance, community misconceptions, and improve access to healthcare.
  20. Determine needs for more frequent patient follow up as informed by metric review to reduce hospitalizations and ED visits for at-risk patients served by TTC grant services.
  21. Compile and report data to TTC committee and FMC care team providers meetings and disseminate reports prior to meetings to TTC committee members.
  22. Attend all TTC grant meetings and participate actively in group discussion as key stakeholder.
  23. Ensure HIPAA enforcement and maintenance of confidentiality at the individual level and among all team members.
  24. Develop long-range plans to make this grant-funded job sustainable with Mcleod Health Diabetes Center of Excellence in conjunction with FMC Medical Director and McLeod Director of Chronic Care Management/Diabetes Services.
  25. Other duties as identified by team members and self and delegated by FMC medical director, Center Director and FMC administrator.


Qualifications /Training:


  • 3- 5 years med-surg clinical experience, diabetes background
  • CDE preferred or will obtain in 1 year following hire, funded by FMC.
  • Experienced with MS Office- Word, Excel
  • Effective oral, written, communication skills.
  • Prior charge nurse/supervisory skills or case management preferred.
  • Works well independently with strong organization, collaboration, and time management skills.
  • Knowledge of clinical practices, diagnostic and treatment procedures.
  • Ability to use good clinical judgement, prioritization skills, critical thinking skills, and adapt/apply guidelines and protocols.
  • Will obtain 15 CEU credits within 3 months of hire in diabetes.

Full time


Florence, SC, United States


Full time

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