Chronic Care Nurse




Title:  Chronic Care Nurse
Schedule: Monday through Friday, 8 am to 5 pm
Location:  Longview, WA
Classification: Full-time
Opening Date: December 12, 2018
Salary Range:  $35.00 00 to $38.46 DOE
Closing Date:   January 12, 2019 or until filled 

Position Summary:  This is a full-time position exempt position within the Cowlitz Indian Tribe’s Health and Human Services Department in Longview, WA.  This position is responsible for aiding patients in managing chronic illness.  The focus of this position is to reduce the long-term effects of chronic illnesses through the behavioral health and other human service interventions. This position will also work with patients to ensure that patients receive all care outlined in the multi-disciplinary plan of care including both internal and external sources.

Essential Duties and Responsibilities include the following, but are not limited to:

  • Works with multi-disciplinary team to address patient needs outlined in patient care plan.
  • Support an on-going person-centered planning process;
  • Assess clinical risk and needs by conducting an assessment process that includes an Initial Screening, Health History, and Bio-psychosocial assessment.
  • Facilitate timely access to primary care, specialty care, Behavioral Health (BH), Substance Use Disorder (SUD), and Intellectual/Developmental Disabilities (I/DD) services, medications, and other health services needed by the patient, including referrals to address any physical or cognitive barriers or referrals;
  • Create and maintain a registry for each patient to manage communication and information regarding referrals, transitions, and care delivery;
  • Facilitate communication among the patient’s providers through the use of electronic health record and other methods of communication including secure e-mail, fax, telephone, and written correspondence;
  • Notify care team of the patient’s hospitalization (psychiatric or acute) and coordinate discharge plan, if applicable;
  • Facilitate face-to-face meetings, conference calls, and other activities of the care team, as needed or requested by the patient;
  • Facilitate direct communication between the provider and the patient or the patient’s authorized representative and/or family or informal supports, as appropriate;
  • Facilitate patient and family education;
  • Coordinate and communicate, as applicable, with the other case managers and staff to ensure timely, non-duplicative supports and services are provided;
  • Following the person-centered planning process, develop with the patient and Integrated Care Team a multi-disciplinary treatment plans (MDTP) specific to individual needs and preferences, and monitor and update the plan at least annually or following a significant change in needs or other factors;
  • Coordinate and make referrals to community resources (e.g. housing, home delivered meals, energy assistance programs) to meet care plan goals;
  • Perform ongoing care coordination;
  • Monitor the implementation of the plan of care with the patient, including facilitating the patient’s evaluation of the process, progress and outcomes and identifying barriers and facilitate problem resolution and follow-up;
  • Advocate with or on behalf of the patient, as needed, to ensure successful implementation of the individual care plan;
  • Support transitions of care when the patient moves between care settings
  • Triages patients and calls as needed.


  • Bachelor Degree in Nursing.


  • Must possess license as a registered nurse, nurse practitioner, or physician assistant 
  • Must have a valid driver’s license.


  • Intermediate level use of Microsoft products, specifically Word and Excel
  • 2 years experience working as a case manager, in home health, or equivalent.
  • 1 year working in a Tribal or Indian Health Service facility as a nurse preferred.


  • Read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
  • Write reports, business correspondence, and procedure manuals.
  • Effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
  • Ability to work with mathematical concepts such as probability and statistical inference, and formulas.
  • Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
  • Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
  • Ability to effectively utilize electronic health records with a high level of accuracy.

The Cowlitz Indian Tribe is an Equal Opportunity Employer, and a Drug & Alcohol-Free workplace.

Except as provided by Title 25 CFR, Section 472 which allows for Indian preference in hiring, the Cowlitz Indian Tribe does not discriminate on the basis of race, color, creed, age, sex, national origin, physical handicap, marital status, politics, or membership or non-membership in an employee organization.

Please mail resume and cover letter to: Human Resources Department
Cowlitz Indian Tribe
P.O. Box 2547
Longview, WA 98632
(360) 578-1641

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