Provides care management in the ambulatory health care setting according to Cherokee Nation standing orders, policies, and guidelines. Participates as a crucial member of the care team which may include a provider, licensed practical nurse, medical assistants, and the patient panel.
Routine duties shall include providing health care services to individuals eligible for services in accordance with the self-governance compact and funding agreement between the Cherokee Nation and the United States executed under the authority of the Indian Self-Determination and Education Assistance Act. Does previsit planning for scheduled patients. Communicates the patient needs and recommended treatment to the staff on their team. Maintains and updates the team's patient panels. Identifies, creates, and maintains panels of high risk sub populations for care management. Tracks performance measures monthly and shares with the team, staff, and patients. Participates in ongoing quality improvement activities using the Model for Improvement. Contacts patients for follow up diagnostic tests, referrals, appointments, or medical follow up as appropriate. Schedules nursing visits for follow up. Tracks and follows up on referrals. Provides patient education and self management support. triages patients on the team's panels who call or walk in and directs them appropriately. Documents observations, assessments, nursing interventions, treatments, and referrals according to CN documentation standards. Provides direct nursing care back up as the team needs dictate. Other duties may be assigned.
Associates degree from 2-year college or technical school in Nursing; no substitutions.
No additional experience.
To perform this job successfully, an individual should have knowledge of Database software; Spreadsheet software, and Word Processing software.
CERTIFICATES, LICENSES, REGISTRATIONS
Must be currently licensed by the Oklahoma State Board of Nursing as a Registered Nurse. Must be certified in CPR and maintain throughout employment. Must obtain Advanced Cardiac Life Support (ACLS) certification within one year of employment and maintain throughout employment. Must possess a valid driver's license with a driving history verified through a motor vehicle report that meets requirements for Cherokee Nation underwriting rating. Must meet and maintain pre-employment an periodic background investigation and adjudication for child care.