Nurse Care Manager (RN) - Care Coordination Leader

Care Manager Nurse (RN) job at Great Plains Tribal Health. Rapid City, SD.

This position is responsible for providing nursing patient care in the outpatient or urgent care setting, in collaboration with Medical Providers and other members of the care team. Will also be responsible for promoting the efficient and effective use of a variety of health care resources by focusing on the whole patient to provide a seamless continuum of care for Oyate Health Center (OHC).

This position assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet an individual’s needs, using communications and available resources to promote quality, cost effective outcomes. Monitors departmental flow to ensure quality care is provided the highest quality nursing care to Oyate Health Center (OHC) patients.

• Obtains the initial screening history on patients being seen in the clinic; performs visual assessment, observation, obtains required vital signs, review of health care reminders and immunization status and appropriate physical assessment.
• Maintains awareness of comfort and safety needs of the patient; explains procedures and treatments to the patient to gain cooperation, understanding, and allay apprehension.
• Aids medical provider during treatment and examination of patient when requested.
• Screen patients and assess health problems and observes patient’s clinical conditions, recognizing serious situations informing the medical provider while taking appropriate preplanned measures.
• Operates and monitors medical equipment such as suction apparatus, nasogastric suction, defibrillator machine, automatic external defibrillator, scales, vital sign machines, IV Pumps, EKG machine, and all other applicable medical equipment.
• Administers prescribed medications, including oral, topical, parenteral, intravenous, rectal, and through other administration routes, and assesses the patient's response to medication;
  Assesses a patient prior to medication administration or oxygen administration, and documents this assessment appropriately;
  Uses a systematic process to determine the efficacy of medication administration, and determines the appropriate action to take when medication administered are ineffective or have limited effectiveness.
• Administers oxygen therapy as appropriate, documenting the patient's response to oxygen therapy and the process of administration and takes appropriate action when oxygen therapy is ineffective or has limited effectiveness.
• Maintains accountability for delivery of quality nursing care;
  Communicates with medical providers, supervisor, to obtain diagnostic and therapeutic assistance and coordination of needs.
• Collects specimens and orders appropriate laboratory and x‑ray studies as authorized by the medical provider.
• Identify cases with potential for high‑risk complications; act as an advocate for an individual's health care needs;
  Understand methods for assessing an individual's present level of physical/mental impairment;
  Assist individuals with the development of short‑and‑long‑term health goals;
  Understand the psychological characteristics of wellness.
• Manage OHC high‑risk patient registry;
  Oversee systems for identifying high risk patients through electronic health record and referrals;
  Ensure validity of registry and collaborate with Information Technology on registry functionality.
• Develop and maintain a tracking system for patient care coordination and care management across the continuum, including care transitions, Primary and Specialty care, tracking referred patients for admission to other healthcare facilities;
  Performs chart reviews to determine timeliness of requested service to facilitate the return of patients.
• Provides technical assistance to CHS staff for clinical issues for their assigned patients. Responds to insurance providers, third party agencies to insure maximum reimbursement to minimize cost on clinical issues.
• Implement and monitor CHEF program for CHS department, including case reviews and assures documentation is prepared and submitted timely for re‑reimbursement.
• Conduct comprehensive assessment of…