Summary: The Registered Nurse for Chronic Care will be responsible for providing care and health education to members of the community, assessing health risks and needs, developing care plans, and coordinating medical services for patients being discharged. Provide led nursing in the community through home visits, telephone consultations and case management.

Essential Duties And Responsibilities:

Ability to work independently and follow standing orders under the direction of the Medical Director, follow providers order for treatments, injections and all other procedures within the Registered Nurse scope of practice. Provide Case management for patients discharged from the hospital, rehabs and nursing homes to assure continuity of care. Identify actual and potential health problems in the home and in the community. Participate in community health initiatives and outreach programs. Collaborate with local organizations to promote health education and access to care. Participate in primary care nursing specific to the Chronic Care program and make referrals to appropriate agencies. Provide education to community members regarding health maintenance, disease prevention and self-care. Educate, counsel, and support individuals and their families on adopting healthy behaviors so they can manage chronic conditions. Provide health screening and assessments for Health Services employees. Participate in ongoing professional development activities, including attending workshops, seminars and training sessions. Stay current with best practices and advancements in nursing care. Prepares patients for examination and obtains specimens as indicated. Document patient care in EHR in a timely manner and maintain accurate records. Assist in managing medical supplies and equipment inventory. Ensure that necessary supplies are stocked and available for patient care, and report any shortages to the appropriate personnel. Perform wound care and dressing changes as required, following established protocols to prevent infection and promote healing. Assess wounds for signs of infection. Participate in rotations for 24/7 on-call service to serve our wound and chronic care patients. Work collaboratively with medical department providers and nursing staff to develop and implement patient care plans, report patient progress and care strategies. Participate in flu and other vaccine clinics as necessary. To accept other duties as assigned.

Supervisory Responsibilities: There are no supervisor requirements for this position.

QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions. Due to the sensitive nature of information obtained, must maintain strict confidentiality at all times.

Obtain Wound care certification within one year of hiring. Complete BLS training within one year of hiring

Education And/or Experience:

Registered Nurse from accredited nursing program in the United States, AND Two years related experience in chronic disease case management.

St. Regis Mohawk Tribe

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