RN Care Manager - Clinic - Okemah

MINIMUM QUALIFICATIONS Education – A Bachelor’s Degree in Nursing (BSN) received from an accredited school of professional nursing is preferred. Experience – A minimum of one (1) year related experience in a relevant job position. Licenses & Certification - Must possess current State of Oklahoma Nursing licensure and Driver’s License. Incumbent must be insurable. Certification as a Diabetes Educator (CDE) would benefit potential incumbent. Knowledge & Skills – Professional knowledge of nursing care principles, TQM ethics, practices and process required to assess nursing needs of assigned patients. Knowledge of diabetes and its relation to cardiovascular disease and associated abnormalities. Ability to develop, implement and evaluate a treatment plan to meet the need of assigned patients. Ability to provide patient services in accordance to established protocol and guidelines set forth by the Diabetes Program. Ability to utilize a personal computer and its applications in a Windows environment. Ability to communicate courteously and effectively with patients and their families, medical and administrative staff, health care professionals and the general public both orally and in writing. JOB SUMMARY The purpose of this position is to provide case management to patients needing chronic care management and transitional care management in the clinic setting. Incumbent monitors patient progress and coordinates clinic and community resources to assist patients in reaching healthy outcomes. WORK ENVIRONMENT Work is performed in a clinical and/or hospital environment. There is common exposure to contagious disease. The work may include a certain amount of exposure to hostile and emotionally disturbed patients, families and visitors. Special attire may be required as protection against infection. Driving a GSA vehicle is required. PHYSICAL DEMANDS The work requires the demands of normal office setting and working within MCNDH clinics and community facilities throughout the MCN. Driving a GSA vehicle to the various work facilities is required. Must have a valid driver’s license and be insurable. ESSENTIAL FUNCTIONS Satisfactory job performance will be determined by successful execution of the following: Provide transitional and chronic care management for MCNDH patients. Conduct initial patient assessment to establish baseline measures, assess patients for tobacco use, aspirin use, stress level and medication change either by face-to-face or non-face-to-face visits. Monitor Electronic Health Records and information exchange systems to assess most recent hospitalization, emergency room discharge, and medication changes. Communicate most recent hospitalization, emergency room discharge and medication changes to provider utilizing electronic health record. Coordinate and utilize clinic, community and other available resources to assist patients in reaching established disease prevention targets. Schedule weekly, monthly or as needed visits with participants to track patient progress. Prepare flow sheets to manage and monitor risk factors and treatment. Provide education to patient, family, guardian, and/or caretaker to support self-management, independent living, and activities of daily living. Ensure that participants follow a schedule or regular laboratory tests and other measures as specified by diabetes, CVD, and high-risk disease management standard of care. Maintain open communication and collaborate with primary care team. Regular attendance is required. Performs other duties as required.