Nurse

Job Summary

Provides support for clients, which includes coordinating an array of services designed to improve the health of high needs, high-risk clients. Care coordination responsibilities will include assessment, care planning, monitoring of client status and implementation and coordination of services. Offers clients, providers, and case managers with health-related assessment consultation in order to enhance the development and implementation of the client's plan of care for TXIX and Home & Community Case Management.

Responsibilities

• Coordinates follow-up activities and referrals with other programs including the Family Caregiver Support Program and HCS Medicaid Case Management.
• Provides health-related assessment and consultation in development of the plan of care through the CARE Tool to case managers.
• Completes Skin Care Protocol based on the ALTSA Long Term Care Manual.
• Identifies and addresses barriers to overcome and impediments to accessing health care and social services.
• Engages clients in care coordination activities designed to promote improved utilization of health care services, including the creation and ongoing maintenance of a patient-centered, goal oriented Health Action Plan.
• Assesses activation level for self-care through use of the Patient Activation Measure® (PAM®).
• Provides evidence-based health assessments and screenings such as; BMI, PHQ-9, Katz ADL, PSC-17, GAD-7, AUDIT or DAST.
• Provides transition support services that coaches the client to build confidence and competence in four conceptual areas, or "pillars": medication self-management, use of a patient-centered health record, primary care and specialist follow-up, and knowledge of red flags of their condition and how to respond.
• Works with supervisors and other health care providers, hospital discharge planners, skilled nursing facility staff, and staff at the client's health home to implement services and analyze the disposition of cases.
• Performs facility visits, home visits, and follow up telephone calls to develop critical coaching relationships, to empower clients to take an active and informed role in their discharge planning.
• Captures and maintains complete and concise client files in compliance with policy to appropriately document activities performed for the client and all elements required for specific programs.
• Maintains all required documentation related to services provided and conforms to monthly deadlines.
• Participates in staff meetings, public education and provider training sessions, as appropriate.
• Develops and maintains relationships with community agencies and organizations that have the potential to provide resource support to the program or individuals.
• Prepares correspondence, memos, and client related written materials, as appropriate.
• Participates in continuing education and training programs.
• Works collaboratively with multi-disciplinary teams involving nurses, case managers and case aides.
• Attends required meetings and trainings.

Qualifications

• Current Washington State Nurses License as a Registered Nurse with a BSN, or is in the process of obtaining an RN, BSN degree Washington State License within 3 months of employment.
• Two years of nursing experience.
• Maintain 45 CEU's every three years in accordance with the State of Washington.
• Pass pre-employment background check.
• Pass pre-employment drug and alcohol test.
• Valid Washington State Driver's License with the ability to obtain a Yakama Nation Driving Permit.