RN Care Manager - Cherokee County Clinic - $5,000 Hiring Bonuw

Job Title: RN Care Manager

Job Code: RNCM 

Department: Primary Care/Diabetes/Snowbird/Peds/CCC

Division: Nursing

Salary Level: Non-Exempt 12 

Reports to: RN Lead/Primary Care DON

Last Revised: March 2022

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.

Job Description

• 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 time frames 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 devises, 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.