Care Manager Nurse (RN)

Job Description

Job Description

Job Summary: 

This position is responsible for providing nursing patient care in the outpatient or urgent care setting, in collaboration with Medical Providers and other members of the care team. Will also be responsible for promoting the efficient and effective use of a variety of health care resources by focusing on the whole patient to provide a seamless continuum of care for Oyate Health Center (OHC). This position assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet an individual’s needs, using communications and available resources to promote quality, cost effective outcomes.  Monitors departmental flow to ensure quality care is provided the highest quality nursing care to Oyate Health Center (OHC) patients. 

Essential Functions:

• Obtains the initial screening history on patients being seen in the clinic; performs visual assessment, observation, obtains required vital signs, review of health care reminders and immunization status and appropriate physical assessment. 

• Maintains awareness of comfort and safety needs of the patient; explains procedures and treatments to the patient to gain cooperation, understanding, and allay apprehension. 

• Aids medical provider during treatment and examination of patient when requested. 

• Screen patients and assess health problems and observes patient’s clinical conditions, recognizing serious situations informing the medical provider while taking appropriate preplanned measures.   

•Operates and monitors medical equipment such as suction apparatus, nasogastric suction, defibrillator machine, automatic external defibrillator, scales, vital sign machines, IV Pumps, EKG machine, and all other applicable medical equipment. 

• Administers prescribed medications, including oral, topical, parenteral, intravenous, rectal, and through other administration routes, and assesses the patient's response to medication; Assesses a patient prior to medication administration or oxygen administration, and documents this assessment appropriately; Uses a systematic process to determine the efficacy of medication administration, and determines the appropriate action to take when medication administered are ineffective or have limited effectiveness. 

• Administers oxygen therapy as appropriate, documenting the patient's response to oxygen therapy and the process of administration and takes appropriate action when oxygen therapy is ineffective or has limited effectiveness. 

• Maintains accountability for delivery of quality nursing care; Communicates with medical providers, supervisor, to obtain diagnostic and therapeutic assistance and coordination of needs. 

• Collects specimens and orders appropriate laboratory and x-ray studies as authorized by the medical provider. 

• Identify cases with potential for high-risk complications; act as an advocate for an individual's health care needs; Understand methods for assessing an individual's present level of physical/mental impairment; Assist individuals with the development of short-and-long-term health goals; Understand the psychological characteristics of wellness. 

• Manage OHC high-risk patient registry; Oversee systems for identifying high risk patients through electronic health record and referrals; Ensure validity of registry and collaborate with Information Technology on registry functionality. 

• Develop and maintain a tracking system for patient care coordination and care management across the continuum, including care transitions, Primary and Specialty care, tracking referred patients for admission to other healthcare facilities; Performs chart reviews to determine timeliness of requested service to facilitate the return of patients.

• Provides technical assistance to CHS staff for clinical issues for their assigned patients. Responds to insurance providers, third party agencies to insure maximum reimbursement to minimize cost on clinical issues. 

• Implement and monitor CHEF program for CHS department, including case reviews and assures documentation is prepared and submitted timely for re-imbursement. 

• Conduct comprehensive assessment of patients’ physical, mental, and psychosocial needs; Collect indepth information about a person's situation and functioning to identify needs in order to develop a comprehensive Care Management plan that will address those needs. 

• Develop care plans to prevent disease exacerbation, improve outcomes, increase patient engagement in self-care, decrease risk status, minimize hospital and emergency room utilization, and are obtainable and concise with the patient needs and goals.

• Utilize behavioral strategies to help patients adopt healthy behaviors and improve self-care in chronic disease management; Promote self-management goals. 

• Assist patients in navigating the health care system; Coordinate Specialty care, follow-up on test results and other care coordination needs; Execute specific care management activities and/or interventions that will lead to accomplishing the goals set forth in the case management plan. 

• Partner with external care management programs to coordinate care. 

• Provide ongoing evaluation and documentation of patient progress/risk status and communicate with care teams. 

• Gather sufficient information from all relevant sources about the case management plan and its activities and/or services to enable the case manager to determine the effectiveness of the plan.

• Record accurate, timely and appropriate information in the patient’s electronic health record; Document observations, nursing interventions, therapeutic measures administered and status of coordinated activities between nursing and other professional disciplines. 

• Initiates a patient education plan according to the individualized needs of the patient, as prescribed by medical provider and/or OHC policy, including patient and family instruction; notifies patient of lab results and provides advice to patients per provider instruction.

• Assists with referrals and/or follow-up care based on results of laboratory and radiology reports, and the mental health and well-being of the patient as recommended by the medical provider. 

• Responds to life saving situations based upon nursing standards, policies, code procedures, and established protocol. Participates in quality improvement activities such as GPRA, PI, IPC, nursing audits/peer review, infection control, case management and nursing care conferences. 

• Must comply with federal laws and regulations as required by the Health Insurance Portability and Accountability Act (HIPPA). 

• Performs other related duties.

Requirements:

• Participates in Core Connections training and applies GPTLHB Core Connections concepts and practices in their work.                                                   • Familiarity and/or experience working with American Indian populations and respect for and knowledge of traditional, cultural, and spiritual practices of diverse American Indian communities, as well as an ability to work with other culturally and ethnically diverse populations.                                                                                                               

• Possess the ability to resolve issues with other departments and coworkers without direct supervision.                                                                             • Able to exercise flexibility to alter plans/routines when situations require and continue to perform without projecting stress/frustration that would adversely affect the work environment.                                                                                                                                                                                      • Ability to maintain a flexible work schedule, including evenings, weekends and overnight or extended travel, as necessary.                                            • Ability to effectively present information in one-on-one and small group situations to community members, consumers, and other employees of the organization.                     

• Proficiency with computer programs (Word, Excel, PowerPoint) and other Internet technologies.                                                                                         •Valid driver’s license must be kept current, and certificates, credentials or licenses must be kept current and consistent with regulations required by applicable federal, state and/or grant regulations. 

Minimum Education & Experience Requirements:

Bachelor’s degree, or associate’s degree and three (3) years’ experience. 

Licensed as a Registered Nurse by any US State or Territory.

This is a professional and/or supervisory position that requires post-secondary education and/or considerable experience, or clinical degrees requiring a clinical rotation. Individuals must have applicable education and/or experience applying basic principles, concepts, and methodology of a professional or administrative occupation, and skill in applying this knowledge in carrying out elementary assignments, operations, or procedures, or experience perform assignments such as carrying out limited projects that involve use of specialized complicated techniques.

The GPTLHB is a tribal organization that follows tribal preference laws. Our policy is to give preference to qualified Indian/Tribal candidates over qualified non-native candidates in hiring decisions if all other qualifications are equal. 

Employment is contingent upon the outcome of all required criminal background checks. 

Compliance with our Employee Health Procedure is a condition of employment.  You are required to agree that you will comply with all job-related employee health screening and immunizations prior to your first day of employment.  Jobs require that you have documentation that you have completed the following immunizations prior to your first day of employment: MMR (Measles, Mumps and Rubella, Varicella (Chicken Pox), Hepatitis B, Influenza, T-dap (Tetanus - Diphtheria - Pertussis), and COVID-19 vaccination is required.