CLOSING DATE: Open Until Filled (OUF)

Salary Range: Dependent on Experience (DOE)

**APPLICANT MUST HAVE A VALID, UNRESTRICTED INSURABLE DRIVER’S LICENSE**

** RESUME AND REFERENCES ARE REQUIRED**

ESSENTIAL DUTIES, FUNCTIONS AND RESPONSIBILITIES:

• Develops and implements comprehensive care plans with patient, family, team (emergency plan, medical summary, and action plan as appropriate), and evaluates and continually monitors/updates/alters these plans based on patient/family needs and unmet needs, strengths, and assets.
• Coordinates inter-organizationally with family, Ambulatory Clinics, inpatient services, and involved services and agencies; facilitate "wrap around" meetings or team conferences and attend community meetings with family as necessary. Observes and assess health status of patients by physical assessment and examination, interviewing patient and family member, and reviewing patient's health history.
• Cultivates and supports assigned care & subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan.
• Educates, counsels, supports and provides patient appropriate anticipatory guidance. In a crisis, intervenes or facilitate referrals appropriately.
• Builds care relationships and patient-specific skills among family and team; supports the primary care-giving role of the family. Facilitates patient/family access to available medical, psychological, developmental, educational, social, and financial services and supports.
• Assists with or promotes the identification of patient with chronic care needs; adds to and maintains chronic disease registry and uses registry to plan and monitor care; properly applies inclusion/exclusion criteria and case finding strategies so as not to over or under identify patients.
• Understands eligibility requirements, referral processes, and funding details for available public and private sector services and programs; catalogs these details and formulates procedures that facilitate access to these services as dictated by individual patient need.
• Serves as the point-of-contact, advocate, and informational resource for family and community partners/payers, including having a close working relationship with the FDIHB Purchase Referred Care Department.
• Serves as a consultant and resource person to FDIHB staff, including physicians, nurses, therapists, pharmacists, dentists, etc. on issues regarding patients and their care.
• Develops and maintains policies and procedures related to the care and care coordination of complex patients with chronic diseases.
• Develops and maintains policies and procedures related to the screening of patients for the presence of complex, chronic medical issues according to relevant standards and guidelines.
• Develops formal referral forms, policies, and procedures that relate to accessing these services and supports.
• Serves as a quality improvement team member; helps to measure quality and to identify, test, refine and implement practice improvements.
• Maintains professional growth and development through seminars, workshops, independent study, and professional affiliations to keep abreast of the latest trends related to patients with chronic disease, throughout the care continuum.
• Attends to specific clinical needs of empaneled complex patients on an as needed basis in the clinic and/or on the inpatient unit. Closely collaborates with the primary care provider (Physician, Advanced Practice Clinician) and the clinical nurses in these instances.
• Provides skilled and comprehensive nursing care to patients for work performed on the mobile health unit, which may include after hours and weekends.
• Offers outreach and education to the community related to chronic care patients, their issues, their needs, and details regarding the function of the Chronic Care Model in the form of presentations and informational sessions.
• Develops and maintains related educational materials and provides instruction or other learning opportunities to meet the needs of the target audience.
• Utilizes theories and principles of education/learning (age-specific, developmentally and culturally appropriate) to foster the educational development of the target audience.
• Fields queries from the community regarding patients with chronic care diseases and issues related to this patient population.
• Completes all yearly Center for Medicare and Medicaid Services (CMS) required training by the indicated dues date.
• Assists, promotes, and supports compliance with established CMS standards.
• Performs other duties as assigned.

MANDATORY MINIMUM QUALIFICATIONS:Experience:

Two (2) years of Registered Nurse experience in clinical, medical/surgical, acute and/or critical care setting.

Education:

Associate of Science degree in Nursing from an accredited nursing program.

License:

Valid and unrestricted Registered Nurse license in any U.S. State or Territory.

Certificate:

Valid American Heart Association certification in Basic Life Support (BLS) and maintain certification.

**Please email degree, transcripts, license and certifications to Cynthia.Morris@fdihb.org.

NAVAJO/INDIAN PREFERENCE:

FDIHB and its facilities are located within the Navajo Nation and, in accordance with Navajo Nation law, has implemented a Navajo/Indian Preference in Employment Policy. Pursuant to this Policy, applicants who meet the minimum qualifications for this position and who are enrolled members of the Navajo Nation will be given primary preference in hiring and employment for this position and members of other federally-recognized Indian tribes will be given secondary preference. Other candidates will be considered only after all candidates entitled to primary or secondary preference have been fully considered.