Clinical Care Manager

Overview Primary Function. The incumbent performs nursing procedures to patients of all ages independently within the framework of established policy. The Registered Nurse is a licensed professional nurse responsible for assessment of patients, development, implementation and evaluation of a patient plan of care; administration of therapeutic measures; teaching and counseling of patients and families; and participating in the development of nursing policies and procedures and quality assurance standards. The Registered Nurse is responsible for the delivery of comprehensive health care to patients of all ages, utilizing standards of care and practice, policies, protocols, and procedures. The purpose of the work is to perform the full range of the nursing process from assessment to evaluation. The work affects the physical and psychosocial well being of the patients and their families. Responsibilities Utilizes best practice models to identify, incorporate or develop best practices for panel management. Collaborates with other teams to share and establish best practice for health promotion and disease prevention strategies. Manages panel by addressing and resolving acute care needs and chronic care needs through a team-based approach. Incumbent will be responsible for leading their pod and assisting the Primary Care Provider in panel management that results in meeting facility, national, and regulatory quality indicators. Utilizes iCare to track, monitor, and assure the appropriate follow-up of clients targeting specific indicators. Utilizes the care management platform for documentation of care management functions such as a care needs screening, Comprehensive assessment, and care planning. Also utilizes the dashboards, within the care management platform for population health and related interventions and innovations Utilizes NC Health connects for information gathering and data collections for management of care needs or gaps in care Coordinates and follows up on referrals to outside specialty providers, recent ED visits, and ICC visits. Emphasis is placed on ensuring treatment notes are available to the PCP timely. Participates in the continued development of the role of Case Management in the Patient Centered Medical Home (PCMH) and Advanced Medical Home (AMH and AMH+). Provides standard nursing care for patients throughout the age continuum. Develops implements and evaluates care plans. Promotes health care outcomes with currently accepted clinical practice guidelines. Provides patient education, advice and information on health assessment, disease processes, medications, treatment plans and available community resources. Assesses patient needs using established clinical guidelines, protocols, and pathways. Provides appropriate follow up as directed or per established guidelines. Provides nursing care in accordance with established nursing care standards, participates in routine and specialty clinics, curative, rehabilitative, and preventive nursing care. On rare occasions may be required to participate in emergency care. The incumbent will be evaluated annually on his/her ability to identify, assess, analyze, and evaluate data and solve problems through the CIH Performance Appraisal System. Performs ongoing assessment by actively participating in the determination of meeting the nursing care needs based upon collection and interpretation of data relevant to the health status of the client. Collects data from relevant sources (patient, family, or caregiver) regarding the biological, psychological, social and cultural factors that might influence and impact the health status of the individual and utilizes this data in patient center care plan development. Collects data through observations of appearance and behavior, measurements of physical structure and physiological function, and other information in an effort to place consultations and/or referrals to the correct internal and external resources (Nutrition, Tsali Manor, etc). Interprets data and recognizes existing relationships between data collected and the client’s health status and treatment regimen and determines the client’s need for immediate nursing interventions. Reviews the patient’s health records and health summary, interviewing patients and family members, documenting the chief complaints, medical history, physical and clinical findings, identifying learning needs of the patient and family, and determining priority of care required. Assessment for health prevention, health promotion, restorative, and health maintenance needs is emphasized. The nurse will plan patient care according to individual assessed patient needs and established hospital policies and procedures. Functions as charge nurse when assigned by the Outpatient Administrator; assigns nursing staff according to staff competency and patient complexity and provides technical supervision for staff members, including reviewing procedures; anticipates problems and acts to resolve problems. Develops individualized plan of care with input from the patient, patient’s family, pod members, and anyone else the patient requests to be included for those patients considered “high risk.” Initiates individualized care plan based on assessment of the patient for specific illnesses, injuries, and diseases Social Determinants of Health (SDoH) and human behavior while adhering to appropriate standards of care. Develops expected patient outcomes that are observable and within an adequate period, and are congruent with the patient’s present and potential physical capabilities and behavioral patterns. Implements nursing care according to the established health care plan. May be required to change work schedule to assist in covering for periodic “late clinics.” May be subject to on-call and callback. May be required to rotate between nursing departments including inpatient, satellite clinics, and the emergency department. Participates in cross training of services within the nursing department. Performs nursing interventions including, but not limited to: Detects changes in the patient’s condition and takes appropriate action. Recognizes, identifies and interprets serious situations and immediately decides proper action. Initiates appropriate resuscitative measures in an emergency. Initiates appropriate action when safety measures are required to protect patients. Documents observations, nursing interventions, patient progress, needs, treatments, diagnoses, possible side effects of treatment, teaching, patient response, effectiveness, complications and communicates information to the physician, co-workers and other health personnel. Administers and documents medications per manufacturer guidelines, hospital policy and established protocols and according to State Board of Nursing regulations. Documents all known drug allergies on the medical record and according to protocol. Assures that all medications, treatments and tests are done appropriately and in a timely manner, detects, and reports medication errors. Provides counseling, teaching, and anticipatory guidance to patients and families on preventive, curative and rehabilitation measures involved in health care. Documents all patient education activities within the patients/family’s level of understanding. Provides guidance, leadership, and training to other nursing personnel. Coordinates health care needs through referrals to support services, community, and tribal resources to promote continuity of care. Maintains a safe environment through the practice of Universal Precautions and Body Substance Isolation, medical waste/chemical management and containment. Isolates infected patients. Cleans patient contact areas and equipment according to policies and OSHA regulations. Participates in the development and implementation of performance improvement activities. Identifies and reports risk management issues. Assumes responsibility for the adequacy and appropriateness of supplies and ensures proper functioning of all medical equipment. Maintains cleanliness and orderliness of work areas. Promotes patient advocacy and confidentiality. Serves on Committees as appointed. Maintains and promotes positive and constructive communications and activities within Nursing services, other departments, tribal, and community agencies for purposes of coordinating and understanding of goals and objectives relevant to the population served. Functions appropriately during disasters. Updates and maintains currency/competency in nursing practices and standards by attending training and in-services. Evaluates patient care provided. Directly observes and evaluates patient care. Revises nursing care and care plans to reflect changes in patient needs. Documents nursing care and patient progress according to hospital policy. Participates in ongoing nursing quality assurance program. May be necessary to work when administrative leave is granted if patient care would be compromised. Education, Licensure, Certification, and Experience Bachelor or Associate Degree in nursing from an accredited program required. Minimum of two years of nursing experience preferred Applicant must have an unrestricted valid Registered Nurse license within the state of North Carolina or a state that is accepted as reciprocity. Current Basic Life Support (BLS) minimally required. Can be acquired through the facility within 6 months following appointment to position. Applicant must have a valid North Carolina driver’s license. Job Knowledge Knowledge of principles, practices, techniques, and theories of professional nursing in order to plan and provide nursing care to meet the physical, emotional, spiritual, and socio-cultural needs of patients of all ages; specifically, Infancy (Birth-1 year), Toddler and Early Childhood (2 years), Latency (6-9 years), Preadolescence (10-12 years), Early Adolescence (13-15 years), Adolescence (16-20 years), Adult (21-64 years), and Elderly (65-+ years). Knowledge of the nursing process and its application to clinical practice. Knowledge of the biological aspects of the disease process and illness in order to recognize complications and therapeutic interventions required. Knowledge of medications and dosages in order to recognize desired effects, side effects, and complications of their use. Knowledge and ability to analyze the results of various medical procedures and translate into appropriate nursing interventions. Knowledge and ability to independently plan, manage, and organize work in order to meet priorities, accomplish work within established timeframes and work in stressful situations. Knowledge of the occupational functions of multi-disciplinary health care team. Knowledge of the culture and medical health profile of the patient population. Knowledge and ability to teach and counsel patient/family on health maintenance and disease prevention. Knowledge of available health care programs and community resources. Knowledge of processes and procedures for establishing, revising, continually monitoring, and evaluating standards for the practice of nursing. Knowledge and skills in operating specialized medical equipment, such as monitoring devices, suction pumps, oxygen equipment, etc. Knowledge of problem oriented medical record methods. Knowledge of legal and ethical aspects of nursing. Complexity of Duties The incumbent will be responsible for leading a team (pod) and will be expected to function in a leadership role. The RN role requires flexibility and the ability to lead team members who possess a variety of personalities. The RN role necessitates the incumbent to always maintain a high level of integrity, poise, and control. The nurse provides a full range of comprehensive nursing care that includes assessing patient needs, development of a plan of care, administration of medications and therapeutic measures, operation of specialized medical equipment, evaluation of the plan of care to ensure that the physical and psychosocial needs of the patient are met and counseling and teaching of patient and families. The nurse must recognize and respond appropriately to patient conditions that deviate from normal and identify, analyze, and report on causative factors and reactions. Guidelines consist of professional standards of practice as determined by the nurse practice act, nursing and medical policy and procedures, standing orders, and hospital and agency policies. Complies also with federal, state, accrediting and local regulations. These guidelines are not always specifically applicable to the individual patient or situation and independent judgment is required in selecting the most appropriate guideline, and applying the intent of the guideline to the specific situation at hand. The nurse receives assistance from the Outpatient Administrator with difficult or unusual problems. Supervision Received The nurse independently plans, schedules, and provides nursing care in coordination with the medical care plan and attempts to solve problems only within established procedures. This is done under the supervision of the Outpatient Administrator. The work is evaluated for technical soundness and adherence to professional standards. Responsibility for Accuracy The incumbent has a positive effect upon the recovery of the patient and is responsible for following policies and procedures, which serve as hospital guidelines and prevents errors from occurring. Errors can have a negative patient outcome since the incumbent’s performance affects the health, recovery, and rehabilitation of patients, and the quality of care provided. Evaluations and observations are used to modify and develop clinically appropriate treatment plans. Work can be verified or checked by the immediate supervisor, other health care providers or systems checks, but usually the responsibility for accuracy relies solely on the incumbent. Contacts With Others Contacts are with patients, families, hospital personnel, and community agencies. Contacts with patients, families, and hospital personnel are to exchange, provide, and obtain information concerning the patient’s physical and psychosocial health care problems, and needs. The nurse uses teaching and counseling methods to influence and motivate patient and family behavior. Contacts with other health care or related disciplines within the hospital are for the purpose of collaboration and consultation. Tact, courtesy, and professional conduct are required to maintain positive working relationships. Utmost sensitivity and confidentiality is required when dealing with patients and families. Confidential Data The incumbent has access to highly confidential patient medical and personal information. The Privacy Act of 1974 mandates that the incumbent shall maintain complete confidentiality of all administrative, medical, and all other pertinent information that comes to his/her attention or knowledge. The Act carries both civil and criminal penalties for unlawful disclosure of records. Violations of such confidentiality shall be cause for adverse action. Mental/ Visual/ Physical Work in the various services within the nursing department is mostly sedentary, yet requires walking, standing, bending, pushing, and lifting in helping patients to and from beds, wheelchairs, and stretchers. These same activities are required in moving equipment and medical supplies. Will be subject to frequent interruptions requiring varied responses, which can cause distractions therefore, the incumbent must possess the ability to differentiate and prioritize many tasks at once. Environment Must be flexible in working hours. Work is performed in the clinic setting, which is responsible for treating patients with a wide variety of medical problems. Incumbent may be exposed to communicable diseases. Incumbent is required to comply with Employee Health Program guidelines including current immunization status of identified communicable diseases and safety precautions are sometimes necessary, such as use of personal protective equipment as required by hospital policy. The work environment involves moderate risks of exposure to infectious disease, radiation, electrical hazards, irritant chemicals and explosive gases. Customer Service Consistently demonstrates superior customer service skills to patients/customers by demonstrating characteristics that align with CIHA’s guiding principles and core values. Ensure excellent customer service is provided to all patients/customers by seeking out opportunities to be of service. #J-18808-Ljbffr