Under the direction of the Director of Nursing and Clinical Supports the Nursing Manager will assist patients in accessing and utilizing health care resources. The Nursing Manager will improve health outcomes through coordinating care, educating patients, building trust between patients, family supports and medical providers and enhancing communication and the continuity of care. As a member of a multidisciplinary team, the Nursing Manager will consult with health care team members to coordinate the services of patient education, preventive care and disease management. The Nursing Manager is responsible for the management, provision and evaluation of nursing care in the assigned area/team.

• Review provider schedules and individual charts and assist the care team in coordinating care for visits and for future healthcare needs. Ensure daily team huddle occurs to discuss next day schedule and potential patient concerns or healthcare issues.
• Handle non-appointment related calls from patients. Resolve reason for the call or route to the appropriate party
• Provide an effective communication link between patient and medical staff, including relaying messages from providers, gathering information from patients/family supports for providers, etc.
• Provide direct supervision to assigned clinical support staff and medical assistants. Process time sheets and leave requests to the Nursing Supervisor for approval.
• Maintain an appropriate inventory of pharmaceutical supplies, samples and clinical supplies (including the emergency supplies and kit). Submit monthly supply requisitions to the Director of Nursing.
• Ensure provision of intake assessments which include obtaining and reviewing prior medical records and medical or program related financial data, documenting a complete medical history, assessing cognitive/verbal skills and needs and identifying barriers to accessing healthcare. Follow up with patients when barriers are identified.
• Utilizing standing orders, ensure appropriate provision of laboratory testing, immunizations, TB skin testing and referrals for preventative health needs as indicated by disease management protocols. Identify patient symptoms, vital signs and disabilities and document on patient record.
• Support patients and providers in the medication refill process. Facilitate appropriate patient medication management based on standing orders and protocols. Ensure access to patient assistant prescription plans.
• Ensure all patients are tracked and data entered into systems for follow up and reporting. Review assigned provider pending orders to ensure completion and documentation.
• Ensure completion of prior authorizations, pre-certifications and referrals by referral specialists.
• Coordinate with the providers to ensure that case management services are provided to patient/family supports with multiple co-morbidities, serious, complex or chronic health problems, psychosocial issues or high risk for hospital readmission.
• Coordinates continuity of patient care with patients and families following hospital admission, discharge and emergency room visits.
• Works with the team to develop, implement and carry out programs in chronic disease management for patients with problems such as diabetes, asthma, congestive heart failure, hypertension and depression based on evidence based chronic disease management models. Evaluates outcomes of care with the interdisciplinary team by measuring intervention effectiveness and implementing team recommendations.
• Identify and utilize cultural and community resources. Use and update the directory of resources available within the Center.
• Monitor lifestyle factors affecting health – such as tobacco use, substance abuse, nutrition and physical activity and assist the patient with goal setting to achieve behavioral change.
• Provide individual and family educational interventions including self-management goal setting, counseling and training on the habits, lifestyle changes, supplies and tools necessary to manage the identified disease. Supports patient self-management of disease and behavior modification interventions.
• Assist in the development and maintenance of a library of educational resources including written materials and videos on related health issues. Reviewing materials for language, cultural competency and reading level. Follow up with patients to validate effectiveness of educational process.
• Participates in quality improvement or other activities that promote improvements in organization performance and/or advancing the mission, goals and objectives of Rural Health Services. Activities may include data collection, health outcomes reporting, clinical audits and programmatic evaluation related to Patient Centered Medical Home or other quality standards.
• Participates as a member of Management Team, Patient Centered Medical Home Committee and Quality Improvement Committee.
• Perform other duties as required and/or directed.

• The ability to interact effectively with patients and staff.
• Knowledge of patient teaching, health promotion and disease prevention methods related to routine health care and those designed to address the needs of patients with chronic, disabling health conditions. Content knowledge and expertise in program-specific field.
• Must be certified in Basic Life Support techniques.
• Ability to prioritize multiple tasks and perform efficiently and effectively in a stressful environment.
• Ability to acquire considerable knowledge of the policies, procedures and programs.
• Ability to comprehend, interpret and apply basic laws and regulations to specific situations.
• Ability to assist in the development of department administrative directives as required.
• Ability to assist in root-cause analysis and make effective recommendations as required.
• Ability to prepare clear, sound, accurate and informative reports containing findings, conclusions and recommendations as required.
• Ability to prepare clear, accurate and informative reports of progress of organizational units, results of research and reviews, and annual reports of accomplishments, future goals, and objectives.
• Ability to work effectively with associates, as well as with supervisors, in the various units of the organization.
• Ability to work in a team relationship.

• Successful completion of an accredited School of Nursing and South Carolina licensure as a Registered Nurse
• Experience with clinical teams
• Experience with electronic health records systems
• Experience working in clinical out-patient setting
• Experience working with diverse population groups