Name Guided Care R.N. – 1 or more



PO BOX 278

PABLO MT 59855

(406) 675-2700

PERSONNEL OFFICE FAX: (406) 675-2711


E-mail: melanie.piedalue


****V A C A N C Y   A N N O U N C E M E N T****


            TITLE:                    Guided Care R.N. – 1 or more


            LOCATION:            Tribal Health Department


            SALARY:                Salary Negotiable


            CLOSING DATE:     Thursday, January 24, 2019 @ 5:30 p.m.



Position is a Testing Designated Position within the definition of the CSKT Drug Free Workplace Policy effective January 1, 1998. The successful applicant, if not already employed by the Tribes must pass a pre-hire drug test and serve a mandatory six (6) month probationary period.


Duties of the position include, but are not necessarily limited to the following:    


  • The Guided Care R.N. is a member of community based, patient-centered care team.
  • The Guided Care R.N. manages all aspects of recipient care needs, in collaboration with the recipients’ primary care teams.
  • The Guided Care R.N. ensures Tribal Health recipients receive high-quality patient-centered care that is timely, appropriate, cost effective, sensitive and coordinated to achieve desired clinical outcomes, grounded in our tribal values.
  • The Guided Care R.N. serves as the point of contact, advocate, and informational resource for patients, care team, family/caregiver(s), and community resources.
  • The Guided Care R.N. develops a plan of care in coordination with the patient, primary care provider, and family/caregiver(s) utilizing clinical quality indicators for all patients on case load, including but not limited to patients diagnosed with cancer, hypertension, diabetes, comorbidities, etc.
  • The Guided Care R.N. regularly evaluates plans of care with patients, providers, and care team as needed, develops mutually agreed upon goals, and provide patient/family education and behavior change coaching.
  • The Guided Care R.N. works collaboratively with the health care team including the clinicians, pharmacists, behavioral health specialist, Licensed Clinical Social Worker, Community Health Registered Nurse, and other professional staff.
  • The Guided Care R.N. manage and coordinate all transitions of care including communication of care plan to all providers in all settings of care (ED, hospital, rehabilitation facility, nursing home, home care and specialist).
  • The Guided Care R.N. ensures care coordination is implemented and managed to improve continuity and quality of care.
  • The Guided Care R.N. facilitation of patient and caregiver access to community resources relevant to patient’s needs, including referrals to transportation programs, Meals on Wheels, senior centers, Elder Care Program, etc.
  • The Guided Care R.N. provides direct caregiver support, including ad hoc telephone advise
  • The Guided Care R.N. increases continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals.
  • The Guided Care R.N. engages patients to take an active role in maintaining and/or improving their physical and mental health.
  • The Guided Care R.N. completes documentation of all patient encounters and care coordination activities in the electronic health record promptly and appropriately. 


Request copy of position description for a detailed description of duties and qualifications




  • Graduate of an accredited school of nursing.
  • Current, unrestricted Registered Nurse license from the State of Montana or compact state.
  • Two years nursing experience, chronic disease management preferred
  • Basic Life Support certification.
  • Advanced Cardiac Life Support preferred.
  • Certification in Care Coordination preferred, required within one (1) year of employment.
  • Must maintain proper licensure/certification and registration; if required.
  • Must participate in and support HIPAA training, as needed and required.
  • Must adhere to CSKT social media policy and other CSKT Tribal policies          regarding professional conduct.
  • Must pass a background
  • Valid State of Montana Driver’s License.
  • Completed supplemental background questionnaire.SUBMIT:                                                                                                                                                    
  1. Completed Tribal employment application.
  2. Certified copy of academic transcript.
  3. Completed supplemental background questionnaire.
  4. Proof of enrollment from a federally recognized Tribe if other than CSKT.
  5. If claiming veteran’s preference, a copy of DD214 must be submitted.


SUBMIT ALL OF THE ABOVE TO: Cynthia Matt, Personnel Office, PO Box 278, Pablo MT 59855, Telephone (406) 675-2700 Ext. #1259.


FOR MORE INFORMATION: Shonda Bolen, Tribal Health Department – (406) 675-2700 Ext. #5032                                                   

File name Guided Care R.N 12.18.18.pdf
Size 170.51 KB
File type pdf (Mime type application/pdf)
Owner Cynthia Matt
Date added 12/20/2018 07:43 AM
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Last modified on 12/20/2018 07:46 AM
MD5 checksum 0ef98718647e7b7b16924228595eb030
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