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. 

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.