Position Summary:

The Registered Nurse Care Manager's primary focus is assisting providers and patients in the areas of nursing care management.


Specific duties and responsibilities:

  1. ??? Work as part of the clinic nursing team to provide a full range of nursing services including floor nursing, patient triage, phone advice, case management, Care Team coordination, and patient education.
  2. ??? Work closely with the Primary Care Provider and clinical Care Team in providing Nurse Care Management which may include:

a)??? Coordination of care within primary Care Team

b)??? Proactive management of patients with chronic illness with poor clinical outcomes or with complex healthcare needs

c)??? Assist patients in care management and system navigation with recent critical diagnosis

d)??? Manage critical abnormal lab/DI results

e)??? Assist with the Care Transition for patients discharged from an inpatient setting

f)???? Active participation in Care Team's ?High Risk Case Management? program

g)??? Provide home visits as indicated.

  1. ??? Assess, identify problems, plan goals, monitor and evaluate client plans and develop strategies that meet the clients immediate and long term needs.
  2. ??? Work closely with Primary Care Provider to manage patient ?Care Items? which could include: medication refills per protocol, lab triage, document management, management of durable medical equipment, prior authorizations of needed medications or other services, and other items as needed.
  3. ??? Assist with population management of patient panels.
  4. ??? Assist patients in obtaining appropriate medications and other medical supplies and equipment.
  5. ??? Participate in patient and staff education.
  6. ??? Provide Nurse visits for designated conditions per clinical protocol/Provider request.
  7. ??? Coordinate Care Team support for patients with new health management goal.
  8. Coordinate tracking of patients for follow-up and continuity of care which may include:

a)??? Developing and using practice guidelines and protocols

b)??? Use of flow sheets, problem lists, and medical data bases

c)?? Development and use of critical pathways.

d)?? Tracking outcomes and reporting to primary care provider

e)?? Tracking and expediting referrals.

  1. Assist with discharge planning / home care referrals.
  2. Assist, in collaboration with the Mental Health.
  3. May perform IV insertion/monitoring to include fluid rehydration and/or medication administration as directed by the medical provider.
  4. May perform phlebotomy as directed by the medical provider.
  5. Completes patient assessment/intake including chief complaint, vital signs, height and weight.
  6. Acts as resource for Medical Assistants.
  7. Anticipates the needs of the providers whenever possible.
  8. Ensures that health maintenance needs are reviewed with provider; is aware of age specific screening, GPRA indicators, diabetic health recommendations.
  9. Carries out health maintenance procedures as allowed by standardized procedures.
  10. Administers immunizations per provider order; must be cognizant of immunization schedule as recommended by ACIP (pink book) and California Department of Public Health (CDPH). Ensures correct needle size, length, site, route are adhered to; verifies/double checks with provider.
  11. Perform electrocardiograms (EKG) as directed by the provider.
  12. Administers medications as ordered by the provider; verifies drug, dosage, allergy status prior to administration.
  13. Ensures lab specimens (those sent to the outside lab) are properly processed including paperwork.
  14. Assists providers with paperwork and collection of records needed to ensure quality patient visits.
  15. Assists with inventory and checks expiration dates for supplies and medications as outlined in Nursing Responsibilities and disposes of expired items via lab or Nursing Director.
  16. Adheres to Blood borne Pathogen Control Plan and disposes of sharps per protocol.
  17. Maintains patient confidentiality at all times; abides by HIPPA and other regulations put forth by the various regulatory agencies.
  18. Performs other duties as assigned.

Special Qualifications:

Must be sensitive to the needs of the Native American community which includes culture, traditions, behavioral patterns and background.





  • Analytical ? Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data; Designs work flows and procedures.
  • Problem Solving- Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.
  • Customer Service- Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments.
  • Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things.
  • Oral Communication- Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; Responds well to questions; Demonstrates group presentation skills; Participates in meetings.
  • Written Communication - Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information.
  • Teamwork- Balances team and individual responsibilities; Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit. Puts success of team above own interests; Able to build morale and group commitments to goals and objectives; Supports everyone's efforts to succeed.
  • Quality Management - Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness.
  • Diversity- Shows respect and sensitivity for cultural differences promotes a harassment-free environment; Builds a diverse workforce.
  • Ethics - Treats people with respect; Keeps commitments; inspires the trust of others; Works with integrity and ethically; Upholds organizational values.
  • Judgment-- Displays willingness to make decisions; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions.
  • Planning /Organizing- Prioritizes and plans work activities; Uses time efficiently; Plans for additional resources; Sets goals and objectives; Organizes or schedules other people and their tasks; Develops realistic action plans.
  • Professionalism- Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.
  • Organizational Support - Follows policies and procedures; Completes administrative tasks correctly and on time; supports organization's goals and values; Benefits organization through outside activities; Supports affirmative action and respects diversity.
  • Quality - Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality.
  • Quantity - Meets productivity standards; Completes work in timely manner; Strives to increase productivity; Works quickly.
  • Safety and Security - Observes safety and security procedures; Determines appropriate action beyond guidelines; Reports potentially unsafe conditions; Uses equipment and materials properly.


Physical Requirements:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • While performing the duties of this job, the employee is frequently required to stand, use hands to digitally manipulate keyboard of computer, draw/administer injections and reach with hands and arms.
  • Able to support the weight of others who require assistance in standing, bending, stepping, walking, and/or sitting.
  • Possess a calm demeanor during stressful situations.
  • Capable of following complex directions and effectively communicate internally/externally via telephone and/or in person.
  • Able to read with a high degree of understanding; this position requires reading health, nutrition and/or medical information that necessitates understanding of what is read.
  • Good hearing and vision skills, as the job requires the individual to hear internal/external requests or requirements and to see forms, materials, supplies or information given/gathered internally/externally.

Reasonable accommodations will be given to qualified disabled applicants pursuant to Section 501 of the Rehabilitation Act of 1973, 29 U.S. Code 791, Title 29, and the Americans with Disabilities Act (ADA).

Work Environment:

  • Frequent possible exposure to bloodborne/airborne pathogens or infectious materials.
  • Noise level ranges from quiet to moderate.


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