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Registered Nurse-Community Health Case Management


Provide professional nursing care to members of the Oneida Community utilizing the nursing process in the community health setting. Acting as Case Manager, the Registered Nurse evaluates and treats patients in accordance with orders from the physician. Plans, organizes, and directs home care services to ensure positive patient outcomes. Conduct regular visits to monitor patient’s condition, provide individualized care and patient education. Utilizes resources from the community to plan and direct services to meet the needs of individuals and families within their homes and communities. Managed the delivery of care throughout the course of treatment and delegate appropriate components of care to the Licensed Practical Nurses and Home Care Workers and or Community Health Representatives under his/her supervision. Participates as a member of the interdisciplinary team to provide support and information within the area of skilled nursing. Continuation of this position is contingent upon funding allocations.

The RN Community Health Case Management position performs the following essential functions within the framework of the public health Core Competencies (PHCC) and Home Health Regulations. The duties and responsibilities are not an all-inclusive list but rather a general representation of the duties and responsibilities associated with this position. The duties and responsibilities will be subject to change based on organizational needs and or deemed necessary by the supervisor.

Analytical/Assessment Skills
1. The ability to describe factors affecting the health of Oneida and surrounding communities as it relates to (e.g., equity, income, education, environment, and social disparities as in relates to Indian Country).
2. Assess patient's condition and nursing needs; set goals and utilize appropriate nursing actions to achieve goals.
3. Review available patient information and patient’s history to conduct and document a thorough assessment of patient current and previous illness(es).
4. Complete physical assessment of patient to include but not limited to obtaining vital signs.
5. Assess for and ensure that arrangements for equipment and other necessary items and services are available.
6. Comply with evaluation, treatment, and documentation guidelines.

Policy Development/ Program Planning Skills
7. Influence policies, programs, and services external to the Oneida Comprehensive Health Division and to the Oneida Nation that affect the health of the Oneida and surrounding communities. (e.g., zoning, transportation routes).
8. Development of ongoing strategies for continuous quality improvement of the department.
9. Advocate for the use of evidence in decision making that affects the health of Oneida.

Policy Development/ Program Planning Skills 
10. Adhere to all Tribal Personnel Policies and Procedures, Tribal Standard Operating Procedures, and Area and Program Strategic Plans and Policies.
11. Ensure program compliance by completing necessary reports as required

Communication Skills 
12. Ability to inform and communicate verbally and in writing in diverse and challenging situations with the ability to process information effectively, identify and define problems and make objective decisions.
13. Ability to operate business computers and office equipment, including in a Windows environment, specifically Word, Excel, Access, SharePoint, Teams, and Presentation software.

Cultural Competency Skills
14. Interact with customers, community partners and co-workers with fairness and equity and deliver services free of bias and prejudice.
15. Support and encourage the development and incorporate Oneida Nation culture, tradition, and values into program practices.

Community Dimensions of Practice Skills
16. Network with internal and external programs to obtain and maintain appropriate in-home services.
17. Arrange and/or attend multi-disciplinary treatment meetings when necessary.
18. Coordinate communication among team members to ensure the appropriate care.
19. Prepare reports, presentations, memorandum, and letters as needed.
20. Provide public health related nursing services to individuals, families and the general community to promote wellness and prevent illness. Organize and facilitate health education programs for the Oneida Community.
21. Nursing activities provided in home/field will focus primarily on wellness and prevention services with an emphasis on empowering individuals and families toward greater self-sufficiency.
22. Advocate for the Oneida Individual, family, and/or community as needed to assist in voicing or expressing health concern cases on their behalf.
23. Practice excellent customer service skills always to include, but not limited to addressing customer and employee needs courteously and promptly.
24. Encourage patients to actively participate in their own care by asking questions and educating them on treatment or situations that they don’t understand.
25. Provide counseling to increase individual and/or family capacity for self-care and coping with illness.
26. Assist in other Community Health Nursing Programming as needed.
27. Contribute to a team effort and accomplishes related results as required.
28. Adhere to all Tribal Personnel Policies and Procedures, Tribal Standard Operating Procedures, and Area and Program Strategic Plans and Policies.

Public Health Sciences Skills
29. Seek out and use evidenced based and best practices in programming.
30. Participate in State Tribal and Federal (I.H.S.) sponsored public health initiatives as needed.

Financial Planning and Management Skills
31. Ensures that required documentation is completed thoroughly and accurately to facilitate maximum reimbursement for services required and completed.

Leadership and Systems Thinking Skills
32. Maintain strict department security, confidentiality, and quality to meet professional standards of the department.
33. Participate in all required and necessary training in clinical procedures; coordinate in-service training, continuing education, orientation, competency reviews and other related training.
34. Participate in the continuing education and skills training needs to maintain and expand professional knowledge, skills, and public health nursing duties.
35. Ensure referral and follow up to assist individuals, families, groups, organizations, and community to utilize necessary resources to prevent, resolve problems and/or concerns.
36. Maintain strict department security, confidentiality, and quality to meet professional standards of the department.

Leadership and Systems Thinking Skills 
37. Knowledge and skill and ability to work effectively under pressure or conditions that may be challenging due to deadlines and emergency situations.
38. Ability to work with minimal supervision.

Home Health Agency & Case Management Skills
39. Promotes Home Health Referrals in the health care community.
40. Provide and document nursing care with proper service coding
41. Develops a care plan using health assessment data, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventative, and rehabilitative nursing actions
a. Includes the patient and the family in the planning process
42. Initiates appropriate preventive and rehabilitative nursing procedures
b. Instructs, supervises, and evaluates home health aide care provided every two weeks
43. Instruct Licensed Practical Nurses and Home Health Aides in treatment procedures to be utilized and provide supervision
c. Assess competency on an annual basis and as needed
d. Provide patient specific training to enhance patient outcomes
44. Administers medications and treatments as prescribed by the physician
45. Demonstrates competence and ability to provide care including but not limited to wound care, catheter care, blood draws and IV medications as well as medication assessment, patient education for disease management, and prevention of rehospitalization
46. Participates in on-call duties as defined by the on-call policy
e. The duties of this position may include weekends and holidays
1. Frequently stand, walk, sit, stoop, kneel, crouch, crawl; feel; reach and pull with hands and arms; talk and hear. Occasionally lift and/or move up to fifty (50) pounds.
2. Work is generally performed in a medical office, home setting or office setting with exposure to potentially dangerous materials and situations that require following extensive safety precautions and may include the use of protective equipment and exposure to blood borne pathogens. Exposure to inclement weather. Exposure to latex products on a routine basis.
3. Work environment is not smoke free.
4. Evening and/or weekend work and/or extended hours and irregular shifts may be required.
5. A Tuberculosis (TB) Screening and/or a 2 step TB Skin Test is required within thirty (30) days of employment.

1. Knowledge of applicable federal, state, county and local laws, regulations, and requirements.
2. Knowledge of HIPAA, Workers Compensation, OSHA, Federal, State and Local regulations.
3. Knowledge of current principles, methods and procedures for the delivery of nursing procedures and quality of care.
4. Knowledge of patient care charts and patient histories.
5. Knowledge of current and emerging trends in technologies, techniques, issues, and approaches in area of expertise.
6. Knowledge of emergency medical procedures.
7. Knowledge of related accreditation and certification requirements.
8. Knowledge of clinical operations and procedures of program services.
9. Knowledge of health education theory and practice.
10. Skill in preparing and maintaining patient records.
11. Skill in operating business computers and office machines, including in a Windows environment, specifically Word, Excel, , and presentation software (such as PowerPoint).
12. Skill in analyzing problems, projecting consequences, identifying solutions, and implementing recommendations.
13. Skill in interpersonal relations.
14. Ability to observe, assess, and record symptoms, reactions, and progress.
15. Ability to maintain quality, safety, and/or infection control standards.
16. Ability to educate patients and/or families as to the nature of disease and to provide instruction on proper care and treatment.
17. Ability to clearly communicate medical information to professional practitioners and/or the general public. 18. Ability to communicate effectively in the English language, both verbally and in writing.
19. Ability to establish and maintain professional relationships with individuals of varying social and cultural backgrounds and with vendors and co-workers at all levels.
20. Ability to work both independently and in a team environment.
21. Ability to learn and operate the applicable Wisconsin Department of Health Services Software applications necessary to provide program services, i.e. WAMS, LTCFS.
22. Ability to exercise sound judgment in decision making.
23. Ability to communicate technical information to non-technical personnel.
24. Ability to demonstrate excellence and continually seek improvement in results.
25. Ability to obtain CPR Certification within six (6) weeks of employment. Must maintain certification during tenure of employment.
26. Oneida Certification on reporting Child Abuse and Neglect within ninety (90) days of employment.
27. Must adhere to strict confidentiality in all matters. (Must sign a confidentiality statement prior to employment.)
28. Must complete Health Insurance Portability and Accountability Act (HIPAA) training prior to employment. 29. Must be willing and able to obtain additional education and training.
30. Must pass a pre-employment drug screening. Must adhere to the Nation’s Drug and Alcohol-Free Workplace Policy during employment.
31. Employees are required to have proof of immunity or dates of 2 doses of MMR and proof of immunity or dates of 2 doses of Varicella prior to starting in any position within the Oneida Comprehensive Health Division. Any refusal of vaccination(s) or failure to provide proof of immunity may disqualify the applicant.
32. Must pass a background security check with the Oneida Nation in order to meet the Employment Eligibility Requirements, Tribal/State Compact and/or Oneida Nation Gaming Ordinance as they pertain to the position. A temporary license or Gaming License issued by the Oneida Gaming Commission is required as a condition of employment and continuing employment within the Oneida Nation’s Gaming Division.
33. A valid driver’s license or occupational driver’s license, reliable transportation and insurance is required. Must obtain a Wisconsin driver’s license or occupational driver’s license within thirty (30) days of employment if applicant has an out-ofstate driver’s license. Must be authorized as eligible to operate a Personal and Tribal vehicle under the Oneida Nation’s Vehicle Driver Certification and Fleet Management Law prior to actual start date. Must maintain driver’s eligibility as a condition of employment.

Applicants please clearly state on the application/resume if you meet these qualifications.
1. One (1) year patient care experience in a home health setting as an RN.

Applicants please clearly state how you meet these qualifications on the application/resume.
1. Bachelor of Science in Nursing (BSN)
2. Wisconsin’s Licensed Registered Nurse.

1. Must provide a copy of diploma/degree, license, or certification upon employment.
2. Must have received or be willing to receive the COVID-19 vaccination by date of hire to be considered. Proof of vaccination required.