Chronic Disease Management Clinician

Position Overview

Reporting to the Manager Health Services and in collaboration with My Health Team, the Chronic Disease Management Clinician is responsible for the development and delivery of chronic disease management services, self-management, and prevention programs to address health needs and priorities of the My Health Team patient population. The incumbent works in partnership with My Health Team primary care providers and allied health care professionals, fee-for-service clinic staff, community organizations and Southern Health-Santé Sud staff and programs to provide services and health education programs that maintain and promote the health of the My Health Team patient population. The Chronic Disease Management Clinician assesses My Health Team patient and community needs, identifies patients at risk for illness, strengthens and increases supportive referral networks, supports linkages to community-based resources, provides education on risk management and chronic disease care, and provide chronic disease prevention, management and support.

The incumbent exercises the appropriate level of initiative and independent judgment in determining work priorities, work methods to be employed and action to be taken on unusual matters. The position functions in a manner that is consistent with the mission, vision and values; and the policies of Southern Health-Santé Sud.

Experience

• Minimum two (2) years’ (within the last five years) of related experience in community services, primary health care or primary care clinic setting.
• Proficiency in computer software; experience with electronic medical records preferred.

Education (Degree/Diploma/Certificate)

• Undergraduate degree in a Health Sciences related discipline from an accredited university.
• Other training related to assessment and care of chronic disease an asset (including physical and mental health related).

Certification/Licensure/Registration

• Active practice registration with the respective professional association.
• Diabetes Educator Certification or the ability to attain within 2 years required.
• Asthma and/or Respiratory Educator Certification preferred or the ability to attain within 2 years required.

Qualifications and Skills

• Knowledge of diabetes management.
• Knowledge of current clinical practice guidelines.
• Knowledge and comprehension of mental health and its links to chronic disease.
• Knowledge and understanding of a population health approach, determinants of health, and equity, as it relates to chronic disease.
• Knowledge and understanding of fee-for-service primary care work environment.
• Demonstrated Health Behavior Change Counseling and Motivational Interviewing skills.
• Demonstrated ability to plan, implement and deliver chronic disease management and self-management programming to individuals and groups.
• Demonstrated ability to work in an inter-professional team, promote teamwork, collaboration and partnerships.
• Demonstrated ability to initiate and work independently.
• Demonstrated critical thinking and decision-making skills.
• Demonstrated ability to work in a fast paced, changing environment.
• Demonstrated excellent interpersonal, verbal, and written communication skills.
• Given the cultural diversity of our region, the ability to respect and promote a culturally diverse population is required.
• Proficiency of both official languages is essential for target and designated bilingual positions.
• Demonstrated ability to respect confidentiality including paper, electronic formats and other mediums.
• Good work and attendance record.
• Requires a valid Class 5 driver’s license, an all-purpose insured vehicle and liability insurance of at least $1,000,000.00.

Physical Requirements

• Demonstrated ability to meet the physical and mental demands of the job.
• No hazardous or significantly unpleasant conditions.
• May work occasionally evenings and weekends as necessary.
• Will be required to travel to other regional facilities as the position duties may require.