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.