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Spokane, WA, US(change)
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BSN Job Description
Responsible for managing patient populations with chronic illness and/or multiple co-morbidities. Works in coordination with primary care provider and collaborates with multiple care team members to serve as the point person to an empaneled patient population.  Assists in designing and implementing planned care interventions through a combination of evidence-based guidelines/pathways and individual care planning consistent with patient preferences and functional/lifestyle goals.  As part of a Patient Centered Medical Home, assists in managing care for the identified patient population across the continuum of care.  Provides leadership and continuity of care guidance for patients with chronic diseases and/or complex disease states.  Engages patient and family to educate, counsel and coach related to patient's diagnosis, pathology, medical and nursing treatment plans, discharge needs and health goals.  Uses the Nursing Process to identify potential or actual problems that could lead to an emergency/crisis situation and takes appropriate action to mitigate, including potential barriers to care.  Supports patient self-management utilizing patient activation activities.  Advocates for patients in all settings of care. Keeps all members of the care team informed.  Updates plan of care in collaboration with the patient and care team members.  Seeks out new information that impacts care and ensures it is entered into the medical record and assessed by care team members; updates plan of care accordingly.  Maintains complete documentation of all critical and essential aspects of medical history and information in the patient's record.  Performs all duties in a manner which promotes team concepts and reflects the mission, vision and values of Kootenai Health. Performs other related duties as assigned.
Minimum Qualifications:
State of Idaho Registered Nurse or licensure pending as documented by temporary licensure OR current RN licensure from a state participating in the "multistate privilege to practice" compact with Idaho.
2.     BSN or higher nursing degree required
3.     Certification in relevant nursing area required within one year of eligibility.
4.     BLS by a KH approved program. Previous experience in caring for chronic disease patients required.
5.     3 years' experience in clinical or community health settings preferred. 
6.     Previous Care Coordination, Case Management or Home Health experience preferred.
Knowledge of quality and financial outcomes of patient care processes preferred.
8.     Demonstrates evidence of essential leadership, communication, education, collaboration, and counseling skills.
9.     Proficient in communication technologies (email, cell phone, etc.).
10.  Effective organizational skills and demonstrates ability to maintain accurate notes and records.
11.  Previous experience with health IT systems and data reports preferred.
12.  Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred. 
13.  Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers, as required.
Essential Job Functions (Physical Requirements):
Regular and predictable attendance is an essential job function.
·         Intermittent sitting and walking throughout scheduled shift.
·         Ability to lift up to 35 pounds. 
·         Frequent stooping, bending, reaching, lifting when filing and accessing records.
·         Read charts, dials, equipment settings, literature and other printed and handwritten materials.
·         Communicate with patients, physicians, families and co-workers in person and on telephone.
·         Work with equipment and manipulate equipment settings, computer keyboard, etc.
Work Environment: 
·         Kootenai Health operates 24 hours per day each day of the year; operational needs of departments may require that you be available to work all shifts, weekends and holidays to meet the needs of the patients.
·         Work is normally performed in a typical interior work environment.
Kootenai Care Network
Full Time
Kootenai Health
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Posted February 27, 2018

  • Canada
  • United States
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