Responsible for managing clinic patients’ care, providing comprehensive, individualized care that integrates patients’ cultural practices and beliefs. Case management may include such items as instruction on chronic disease management and medication, pain management, wound care, IV infusion, and post-operative instructions. Coordinated with multidisciplinary teams in the delivery of patient care.

This list is intended only to illustrate the various types of work that may be performed.  The omission of specific statements does not exclude them from the position if the work is similar, related or logical assignment to the position.

1. Guide and assist patients through the healthcare system, assisting with appointments, treatment decisions, understanding their diagnosis and the resources available.
2. Serve as an essential link between the primary care provider in the clinic and the entire care team for the patient.
3. Follows patients throughout the care continuum, including inpatient admissions, and collaborates with inpatient, outpatient and community care management resources.
4. Responsible for the outreach efforts to establish and maintain positive working relationships with key customers (Physicians, office staff, diagnostic staff, nurses, radiology staff, social services staff, and radiation oncology staff, etc.)
5. Act as a patient advocate to ensure their needs and preferences are met throughout the treatment process.
6. Monitor patient progress and provide ongoing support.
7. Functions on the multidisciplinary team as an advocate, educator, and counselor for clinic patients.
8. Work with the providers and public health team in all screening initiatives. Participate in community events and screening awareness.
9. Cover and assist other clinic nurses including pod case management, diabetes care and education, and oncology nursing navigation.
10. Records the health needs of the patient.
11. Evaluates and revises the plan of care, as necessary.
12. Provides nursing services, treatments, and diagnostic procedures requiring specialized skills and assuming full responsibility for each patient. This may include x-ray, burn or wound care, and outpatient procedures.
13. Initiates preventative and rehabilitative nursing procedures as appropriate for the patient’s care and safety. Affecting changes in environment to ensure patient safety and security.
14. Counsels the patient and his/her family in meeting nursing and related needs.
15. Coordinates services for patients as needed to other agencies and healthcare providers as appropriate.
16. Provides reports to the patient’s physician about patient under care when the patent’s condition changes or there are deviations from the plan of care.
17. Prepares clinical and progress notes on the relevant nursing services provided and maintains a clinical record for each patient receiving care.
18. May be assigned to participate in clinic projects such as vaccination and coordination with other tribal departments.
19. Updates knowledge and skills by attending in-service programs, continuing education programs, seminars, and self-study programs annually.
20. Adheres to applicable regulations, policies and procedures.
21. Because of the Tribe’s commitment to community service and the well being of its members, each employee must be expected to perform a wide range of office and field duties from time to time. Such duties may or may not be related to their regular responsibilities.
22. Maintains the privacy and confidentiality of all protected health information in accordance with the divisions policies and procedures, and in compliance with state and federal regulations as applicable.
23. Assess patient healthcare needs and develop individualized care plans whenever needed, but especially for chronic conditions.
24. Work closely with our MEIHSS team.
25. Because of the Tribe's commitment to community service and the well-being of its members, each employee may be expected to perform a wide range of office and field duties from time to time. Such duties may or may not be related to their regular responsibilities.

Required:

• Graduation from an accredited Registered Nurse (RN) program and active Washington State RN license.
• Five (5) years of progressively responsible nursing experience.
• Two (2) years in care coordination, case management, or population health, and
• Two (2) years in a primary care, ambulatory, or community health setting.
• Current Basic Life Support (BLS) certification at time of hire.
• Valid Washington State driver’s license.

Skills:

• Strong communication and interpersonal skills
• Must demonstrate technical competence, communication skills and sensitivity for the family in crisis.
• Organizational and multi-tasking skills are essential.
• EHR skills a must including ability to access and navigate various EHR systems.
• Communicate effectively in both verbal and written form; adapting to changing situations; assessing patients and monitoring performance; comprehending and interpreting records/documents; listening effectively; problem solving; troubleshooting; time management; multi-tasking.

Ability:

• Ability to implement professional and community-based education programs.
• Ability to build positive working relationships with physicians and external agencies.
• Ability to communicate with multiple levels of the organization (e.g. managers, physicians, clinical and support staff).
• Ability to follow verbal and written instructions; observe and record information used to make clinical and program staff decisions; observe and evaluate conditions; reactions and changes in the physical and mental conditions of patient’s communicate effectively; maintain confidentiality.

Knowledge:

• Knowledge of acute illness and chronic disease process and management.
• RN scope of practice techniques and methods; medications and treatments used in patient care; infection control procedures; mental or behavioral characteristics of physically or mentally disabled people.

The working conditions described here are representative of those that must be met by an employee to successfully perform the essential duties of this class. While performing the duties of this job, the employee is frequently required to sit and talk or hear. The employee is occasionally required to walk; use hands to operate, finger, handle or feel objects, tools or controls; and reach with hands and arms. The employee must occasionally lift and/or move up to 30 pounds. specific vision abilities required by this job include close vision and the ability to adjust focus. The noise level in the work environment is usually moderately quiet.