Come make a difference in the lives of people every day while helping us achieve our mission: To improve the health of our patients and communities by delivering exceptional care, removing barriers, and promoting healthy lifestyles.

ROLE: Promotes improved health outcomes and enhanced patient and staff satisfaction within the clinic and community, under the direction of the Chronic Condition Care Program Manager. This position serves as both a patient care manager and a nutrition expert, with a primary focus on evidence-based nutrition therapy, self-management support, and interdisciplinary care for patients with chronic health conditions.

JOB DUTIES:

Direct Patient Care & Chronic Condition Management

· Provide medical nutrition therapy (MNT) and self-management education for patients with chronic conditions (i.e., diabetes, hypertension, chronic kidney disease, hyperlipidemia, and obesity).

· Develop individualized, culturally competent care plans in collaboration with providers, patients, and families; monitor adherence and adjust as needed.

· Deliver one-on-one and group-based education across the lifespan, incorporating nutrition, lifestyle modification, and behavior change strategies.

· Support medication management by assessing diet-related influences and collaborating with medical providers to optimize treatment plans.

· Teach patients self-monitoring skills (e.g., blood glucose, blood pressure, food journaling) and track adherence.

· Provide ongoing nutrition counseling via clinic and telehealth visits.

· Ensure program completion and care coordination including scheduling follow-up visits for DSME, nutrition education, chronic condition management, preventative visits, labs, etc.

· Support patients in accessing and utilizing MyChart.

Integrated Nutrition Education

· Support Chronic Condition Care Program Manager in patient and staff wellness as a content expert for chronic disease prevention and management, especially regarding nutrition and lifestyle medicine.

· Participate in developing nutrition education tools, handouts, and resources tailored to patient populations in collaboration with the Chronic Condition Care Program Manager.

· Integrate motivational interviewing and health coaching strategies into patient and staff education.

· Stay up to date on new programs, guidance, and recommendations with Chronic Condition Care Program Manager.

Community Health & Care Coordination

· Work with community organizations to support food security, access to healthy foods, and culturally relevant resources.

· Collaborate with Behavioral Health, Medical, Dental and Vision providers, along with community partners to provide whole-person care.

· Coordinate patient outreach and education for preventive care and lifestyle-related risk reduction.

· Represent SCHS at community events, health fairs, and conferences.

Quality Improvement & Program Support

· Collaborate with Quality team and provide input on policy development, staff communication, and quality improvement projects related to chronic disease in partnership with Chronic Condition Care Program Manager and Director of Primary Care Integration.

· Assist in managing registries, data tracking, and patient outreach efforts.

· Participate in peer review audits and grant-related activities.

· Contribute to care team meetings and cross-departmental projects.

KNOWLEDGE, SKILLS, AND ABILITIES:

· Strong foundation in medical nutrition therapy, chronic disease management, and lifestyle medicine.

· Skilled in motivational interviewing and patient-centered communication.

· Knowledgeable about the healthcare environment, particularly Federally Qualified Health Centers.

· Effective at collaborating across disciplines (medical, behavioral health, social services).

· Excellent organizational, documentation, and time management skills.

· Proficient in EMR use (OCHIN Epic preferred) and patient portal engagement (MyChart).

· Highly organized, self-motivated, and detail-oriented, with the ability to balance multiple priorities and deadlines.

· Committed to equitable, inclusive, and integrated, whole-person care; Culturally responsive and adaptable to diverse populations.

· Demonstrates relational leadership and trauma-informed principles — able to build trust, foster collaboration, and engage others in shared improvement goals.

· Embodies Southside’s mission, vision, and values in daily work and relationships.

MINIMUM QUALIFICATIONS:

· Registered Dietitian Nutritionist (RD/RDN) required.

· Certified Diabetes Care and Education Specialist (CDCES) strongly preferred; or interested in obtaining CDCES.

· Minimum two years’ experience providing nutrition counseling/education, preferably in chronic disease management.

· At least two years’ experience in a healthcare or community health setting.

· Fluency (written and verbal) in English required; bilingual in Spanish strongly preferred.

· Proficiency with MS Office and basic statistical/analytic tools.

· Reliable transportation, valid driver’s license, and car insurance.

· Flexibility to work occasional evenings/weekends as needed.

WORK ENVIRONMENT AND PHYSICAL DEMANDS:

This position operates in a professional medical clinic/office environment. The role routinely uses standard office equipment. Physical demands include:

Maintain a stationary position for extended periods while performing essential job duties.
Must be able to operate typical office equipment such as computers, fax machines, copiers, and telephones, as well as instruments commonly found in a medica clinic (e.g., diagnostic tools, medical devices).
Requires effective verbal and written communication skills to interact with team members, clients, or patients and to complete necessary documentation.
Discern test results, x-ray results and distinguish physical cues on patients, such as changes in appearance or condition.
Must be able to recognize and respond to potential signs of health issues or alcohol impairment through appropriate sensory or observational means.
Occasional movement throughout the clinic, including moving between different areas to perform essential duties.
Rarely position oneself to retrieve items or perform certain tasks such as connecting or plugging in equipment.
Occasionally ascend/descend stairs, ladders to retrieve items.
May need to move items needed for demonstrations weighing up to 20 lbs short distances.
This position may require regular interaction with individuals who have communicable illnesses, which may pose a risk of exposure to infectious diseases.

Reasonable accommodation can be made for qualified individuals with disabilities to enable them to perform the essential functions of the role.

Nutritionist jobs

Registered Dietician, Chronic Condition Care Manager