SDPI (Special Diabetes Program for Indians) Assistant Coordinator/Case Manager/Lifestyle Coach

The incumbent is responsible for assisting the program in planning, organizing, and coordinating care.

Department:

Health & Wellness

Job Description:

This community-based, grant-funded position serves families of the Pueblo of San Felipe, providing diabetes prevention through coordination and administering grant-required services per the Pueblo of San Felipe Tribal Administration and applicable federal grant-awarding agency. The incumbent is responsible for assisting the program in planning, organizing, and coordinating care, targeting individuals at high health risk, ensuring an integrated flow of services, and coordinating activities, community health programs, and resources for the Special Diabetes Program for Indians (SDPI). Case manager will also function as a Lifestyle Coach as defined by the Centers for Disease Control and the Diabetes Prevention Program to provide peer related, person-centered care and collaboration to enroll, engage, and retain SDPI participants.

Duites:

  • Planning, organizing, and coordinating care, targeting individuals at high health risk, and ensuring an integrated flow of services
  • Coordinate diabetes care with all providers and define roles and responsibilities to avoid duplication of effort.
  • Work with team of providers and community resource to develop evidence-based interventions and action plans.
  • Participate as a member of the multi-disciplinary diabetes team.
  • Assess client needs and preferences.
  • Monitor clients proactively.
  • Arrange transitions between sites of care.
  • Assess local food programs/resources and develop a plan to refer food-insecure families.
  • Make referrals for diabetes services, including specialty care, food assistance, and DSMES.
  • Facilitate access to resources (e.g., health insurance, transportation, food, socialization for homebound elders).
  • Works as an active and independent team member in planning, implementing, and evaluating activities to include group and individual presentations in the clinic and community setting
  • Educate and support caregivers to bolster day-to-day management of person living with diabetes
  • Analyze data to develop a comprehensive picture of the overall diabetes care received and identify current gaps in diabetes care.
  • Identify those at high risk to receive case management services.
  • Identify all services and resources available in the clinical facility, outreach program, and community, especially tribal resources.
  • Coordinates follow-up with community member's program participation.
  • Participates in conference calls and meetings.
  • Assists the Program Coordinator with activity participation reports required by the SDPI grant guidelines.
  • Participates in SDPI team meetings.
  • Works with members of the local interdisciplinary team, local clinic, regional and national education and support organizations.
  • Assists with the implementation of grant objectives and goals as appropriate, including participation in curriculum and community-based requirements.
  • Collaborates and coordinates service delivery closely with health and wellness departments and Indian Health Service medical providers serving the San Felipe Pueblo community for program promotion, education, and teaching.
  • Participates in continuous evaluation of programs and services and performance improvement.
  • Maintains confidentiality of all records and reports maintained for the health program.
  • Knowledge of Indian Health Services (IHS), ISDEAA 96-638, Federal Grants and Contract
  • Seeks out additional funding sources to support ongoing and new programming
  • Establish relationships and rapport with internal and external customers to promote and strengthen diabetes management and prevention within the San Felipe Pueblo community.
  • Other duties and responsibilities as required.

Additional Responsibilities:

  • This position description in no way states or implies that these are the only duties performed by this employee.  He or she will be required to follow any other instructions or to perform any other duties requested by his or her supervisor

Qualifications:

Education:  Within one year, obtain CDCES or equivalent.

Experience/Basic Knowledge:  General knowledge about diabetes, community level interventions and home visiting services

Required Licenses/Certifications: A lifestyle coach who organizes transportation for clients to multiple educational programs offered by the Diabetes Program.  State of New Mexico, current basic CPR certification, current NM State driver’s license.

Physical Requirements: Requires driving and involves standing, bending, and walking within the community, schools, clinics, and homes. Ability to drive a car in all types of road conditions.  Lifting and carrying in necessary to set up equipment for special events, clinics, and teaching programs. Must have manual dexterity to enter and retrieve data from a computer.

Preferences: San Felipe Preference NA/AI, and Veteran’s Preference.

Working Conditions:

The work environment characteristics described here represent those that an employee must meet to perform the essential functions of this job successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform basic functions. Exposure to outside weather in all seasons is necessary because of required visits to home and schools. Travel is often on unpaved roads. Exposure to infections and communicable diseases is possible. May work after hour has and weekends. Works in the office and the community. They may be seated for long periods and require food-insecure families.

Additional Info:

Supervised by the SDPI Coordinator.

Guidelines include Tribal personnel policy, department policies and procedures, and the SDPI grant.

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