# Chronic Care Lead Nurse Job Avenue Healthcare, Nairobi, Kenya Canonical URL: https://primejobalerts.com/jobs/chronic-care-lead-nurse-job-avenue-healthcare-nairobi-kenya Company: Avenue Healthcare Nairobi, Kenya Category: Healthcare & Medical Location: Kenya Work type: Full-time Work arrangement: On-site Published: 2026-08-13 Expires: 2026-09-27 ## Job Description Job Objective/Purpose - The Chronic Care Lead Nurse performs care management for chronically ill patients with chronic diseases such as chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, and/or congestive heart failure. The Chronic Care nurse works in collaboration and continuous partnership with chronically ill patients and their family/caregiver(s), clinic providers and community resources in a team approach to increase patients’ ability for self-management and shared decision- making. ### Key Responsibilities - Fulfill the Avenue health care mission to provide high quality care that exceeds our client expectation with the goal to deliver through courteous, respect and compassionate manner. - Responsible for registry of chronic care management (CCM) to patients. - Validates enrollment of CCM patients based on provider request - Comply with documentation requirements of the Chronic Care Management program by carrying out the care plan with the patient, family/caregiver(s) and providers and recording in the EMR. - Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a timely manner, and facilitates changes as needed. - Creates an ongoing process for patient and family/caregivers(s) to determine and request the level of care coordination support they desire. - Facilitates patient access to appropriate medical and specialty providers. - Coordinates transition of inpatient to outpatient care in an effort to decrease readmission rates - Work closely with in-office providers to manage the day to day calls involving: symptom control, medication management, and provide patient and family education - Educates patient and family/caregiver(s) about relevant community resources. - Assist with the identification of “high-risk” patients (the chronically ill and those with special health care needs), and assist on the enrollment of these to the patient registry. - Coordinates continuity of patient care with external healthcare organizations and facilities including from the primary care provider to a specialty care provider. - Supports patient self-management of disease and behavior modification interventions. - Provides patient health counseling, education and instruction. - Any other duty assigned by your immediate supervisor in line with the job description. Person Specification - Graduate of an accredited nursing school as a Registered Nurse with a Diploma/Degree in Nursing, valid license with the Nursing Council of Kenya. - Updated BLS, ACLS/ATLS certificate - Minimum of 3 years’ work experience in a healthcare setting involving patients with complex chronic disease states preferred. - Customer focus, empathetic and emotional intelligence - Strong interpersonal and communication skills - Organizational awareness and attention to detail - Team work and result oriented - Ethical and reliable ### How to Apply Click here to apply ## Apply Use the canonical Prime Job Alerts page for full application instructions and source verification.