RN Case Manager (4)

Job Description

Job Description:\n\nDescription: POSITION OBJECTIVES The RN Case Manager works collaboratively with providers and other members of the health care team to improve the health of patients with chronic conditions or complex needs. This position educates patients and families to help them manage their health care needs. The RN Case Manager facilitates communication, coordinates services, addresses barriers, and promotes optimal allocation of resources while balancing clinical quality and cost management. The RN Case Manager works for the KTHFS Wellness Center within a scope aligned with the Primary Care Clinical Program initiatives. Patient interactions may be in person, by telephone, or other electronic means. MAJOR DUTIES AND RESPONSIBILITIES General Case Management 1. Identifies patients who meet established criteria for care management (e.g. HgA1c > 8, elevated LDL and/or blood pressure, Mental Health Integration referral, complex resource needs). 2. Manage panel acute and chronic care needs as well as health maintenance, meeting clinic expectations for health maintenance standards. 3. Maintain accurate, complete, timely and professional documentation in health records. Documentation of all patient contacts required, including but not limited to telephone contact with any significant changes for provider to review. Patient Evaluation 4. Assesses family, social, cultural characteristics. 5. Understands communication needs (e.g., vision, hearing). 6. Assesses behavioral and family risk factors. 7. Assesses barriers. 8. Screens for chronic disease (e.g. depression). 9. Reviews patient understanding of medication treatment. 10. Notify provider and appropriate personnel of emergent situations. Chronic Disease Management 11. Utilizes a working knowledge of established care process models and other applicable standards of care. 12. Provides focused patient education using established content and tools. 13. Uses clinician approved and appropriately documented standing orders. 14. Establishes individualized care plan including treatment goals in collaboration with patients and consistent with medical plan of care. 15. Reviews care plan and assess progress toward treatment goals and barriers at each relevant visit. Support Patient in Self-Management and Behavior Change Using Motivational Interviewing and Coaching 16. Assesses readiness to change. 17. Assesses and tracks patient capacity for and confidence in self-care. 18. Provides self-monitoring tools. 19. Provides or connects patients with support programs. 20. Assesses and supports patients in adopting healthy behaviors. 21. Assesses and arranges treatment for mental health and substance abuse problems. 22. Establishes process to monitor patient adherence to medical plan of care. Coordination of Care 23. Coordinates with care managers in other settings as appropriate. 24. Provides information on enabling services (e.g., transportation). 25. Maintains list of key community services agencies with contact information. 26. Provides information about recommended or available services and contacts. Manage Populations, Disease Registries and Preventive Care 27. Focuses on prevention measures consistent with established guidelines and care process models. 28. Reviews and manages quality reports related to chronic disease and prevention. 29. Supports clinicians in achieving quality incentives. 30. Assist with the accurate data entry, tracking and reporting of all statistics for federal, state, I.H.S. and/or grant requirements, including but not limited to immunization reports, GPRA, IHS reports, and meaningful use; as assigned. 31. Works collaboratively with referring provider and other members of care team 32. Complete pre-visit planning (review chart before visit, notify patient of tests needed before the visit) 33. Facilitates advanced care planning (Advanced Directives). 34. Establishes a process for reminder letters and phone calls. 35. Supports clinicians and teams to achieve personalized primary care goals. 36. Facilitates transitions of care (e.g., unscheduled hospital admissions, emergency department visits, skilled nursing homes, and community health). 37. Tracks status of critical referrals by collaborating with the Referral Team. 38. Follows up to obtain report back from referral clinician. 39. Attend clinic team meetings to assist with process design and help resolve team issues. 40. Supports development of agenda for team meetings. 41. Reviews data summary on regular basis. 42. Consistently model appropriate behaviors, attitudes and skills that support the C.L.E.A.R. and H.E.A.R.T. customer-service standards to build positive relationships with patients and KTFHS employees. General Nurse Duties 43. Act as a resource to the clinic. Coach and mentor all clinical team members to build or enhance capability and competency. 44. Respond to emergency situations. 45. Manage Nurse Clinic during provider’s Walk-in/Same Day schedule. Duties include telephone and clinic triage for walk-in/same day patients. Conduct initial health assessment and identify chief complaint. Nurse will coordinate with medical provider for patient needs. 46. Initiate needed therapeutic measures and other general nursing care. Assist the provider as needed. 47. Mentor Integrated Care Team Medical Assistants to improve skill sets. 48. Provide support to the Community Health Nursing Program when appropriate based on organizational need and supervisor direction. 49. Train nursing students, family practice residents, pharmacy students, medical students, and/or any other students in outpatient clinic nursing standards and quality of care, as assigned. 50. Assist in development and implementation of quality improvement projects, and apply knowledge and experience with preparation for regulatory and/or accreditation review or inspections. 51. Assist with the development and review of medical clinic and nursing related policies and procedures in accordance with evidence-based practice, federal and state regulations, and/or accreditation standards. 52. Like all employees of the Klamath Tribes, the incumbent will be called upon to accomplish other tasks that may not be directly related to this position, but are integral to the Klamath Tribes’ broader functions, including but not limited to, assisting during Tribal sponsored cultural, traditional, or community events that enable the successful operation of programs and practices of The Klamath Tribes as aligned with The Klamath Tribes’ Mission Statement. Some of these tasks may be scheduled outside of regular work hours, if necessary. KNOWLEDGE, SKILLS, ABILITIES Knowledge of and the ability to interpret regulatory and accreditation standards. Knowledge of nursing theory and practice. Ability to coordinate clinic activities; work well under pressure and demands for time. Demonstrates ability to successfully coach/mentor/train subordinates for sustained performance improvement. Knowledge of out-patient or ambulatory clinic policies and procedures. Knowledge of sanitation, nutrition, epidemiology and communicable disease control. Knowledge of health care provider operating techniques. Knowledge of children, adult and healthcare worker immunization recommendations and procedures. Ability to prepare and administer medication and injections. Ability to perform specialized medical procedures, including, IV therapy and phlebotomy. Ability to identify medical priorities for patient care and telephone triage. Ability to provide patient education. Ability to effectively work with the public, co-workers, and supervisors; which includes communicating effectively both verbally and in written form. Possess the tact necessary to work effectively with patients, providers and other employees. Must have ability to complete required documentation and required written follow-up. Teamwork skills a must. Demonstrate proficient computer skills for data entry, scheduling and other related duties. Demonstrate ability to accurately maintain records and/or a filing system. Ability to provide telephone triage while “on-call”, including during afterhours and on weekends. Ability to maintain strict confidentiality of medical records and adhere to the standards for health record-keeping, HIPAA and Privacy Act requirements.Requirements: QUALIFICATIONS, EXPERIENCE, EDUCATION Minimum Qualifications: Failure to comply with minimum position requirements may result in termination of employment. · REQUIRED to possess a current State License as a Registered Nurse. For out of state applicants; Oregon Registered Nursing Licensure required within 90 days of hire. (Must submit copy of Licensure with application.) · REQUIRED to acquire and maintain ACLS certification for healthcare providers. · REQUIRED to have basic computer skills, EHR experience, and knowledge of word processing software. · REQUIRED to submit to annual TB skin testing and adhere to KTHFS staff immunization policy in accordance with the Centers for Disease Control immunization recommendations for healthcare workers. · REQUIRED to submit to a background and character investigation, as per Tribal policy. Following hire must immediately report to Human Resource any citation, arrest, conviction for a misdemeanor or felony crime. · REQUIRED to accept the responsibility of a Mandatory Reporter in accordance with the Klamath Tribes Juvenile Ordinance Title 2, Chapter 15.64 and General Council Resolution #2005 003, all Tribal staff are considered mandatory reporters. Preferred Qualifications: · To have a Bachelor’s degree in Nursing (BSN). Education must be obtained from an accredited institution. Degree will be verified. · Three (3) years’ experience working in an ambulatory, inpatient, outpatient, or other relevant clinic settings. · Experience in case management, utilization review, or discharge planning. · Flexible work schedule is strongly preferred. · Positive working experience with Native Americans in a related field will be given preference. Physical Requirements: · Ongoing need for employee to see and read information, labels, monitors, identify equipment and supplies, and be able to assess patient needs. · Frequent interactions with patient care providers, patients, and visitors that require employee to verbally communicate as well as hear and understand spoken information, alarms, needs, and issues quickly and accurately, particularly during emergency situations. · Manual dexterity of hands and fingers to manipulate complex and delicate equipment with precision and accuracy. This includes frequent computer use and typing for documenting patient care, accessing needed information, etc. · Sitting while charting or entering data into a computer. It is also possible that sitting may occur during breaks and meal periods. Total sitting may be up 6 to 8 hours for each eight-hour shift, depending on clinical assignment. · Standing and walking is occasionally required in the clinical area. Standing in one position is required while performing certain aspects of patient care. Walking occurs on vinyl, tile, linoleum, or carpeted floors. · Occasional lifting of medical supplies, medications, and patient supplies, all weighing up to ten pounds is required. Also lifting CPR equipment and other medical equipment weighing up to 45 pounds is required. One is required to assist in lifting and transferring patients of varying weights and is expected to request assistance when lifting, ambulating, and repositioning patients. One must be able to support at least 75 pounds to reposition, transfer, and ambulate patients safely. · Occasional carrying of medical supplies and other items weighing up to 45 pounds is required, along with occasional carrying of certain medical equipment weighing up to 50 pounds. · Pushing/pulling 70-100 pounds is required when administering patient therapy and care, as well as when pushing equipment such as oxygen tanks and monitors, and when transporting patients in wheelchairs or gurneys. Pushing is required at 3.5 pounds of pressure when administering CPR. Full manual dexterity of both upper extremities is required. · Bending is required when administering patient care. One must be able to bend to touch the floor to remove environmental hazards. · Squatting or kneeling is required when operating medical equipment and performing aspects of patient care, such as CPR. · One must have normal hearing (aids permitted) in order to perform physical assessments, including listening with a stethoscope for bowel, heart, and lung sounds. One must also be able to hear to detect subtle, yet critical information regarding patient conditions including alarms, and to communicate with providers and other professionals involved in patient care. · Vision is required within normal limits (glasses or contacts permitted) for monitoring equipment, reading medical data, preparing and administering medications and injections, and performing physical assessments of patients including subtle changes in color. · Depth Perception required for fine tasks such as administering injections or sterile catheter insertions (urinary, IV). · One must have fine motor skills of all fingers and be able to grasp and control medical equipment, and to perform precise procedures such as sterile dressing changes. Ability to grasp objects such as a pen to prepare handwritten reports is also required. · RN must be able to assess patients through palpation with fingers and hands, and must be able to distinguish between warm/cold and be able to feel vibrations. · One must have normal sense of smell to detect odors indicating unsafe conditions or changing patient status. · Employees are responsible for their own transportation to and from work locations.