Nurse Specialist (Case Management)

About the Role

The Nurse Specialist (Case Management) (NCM) provides outpatient case management and self-management education to persons with chronic disease and special healthcare needs. This position may require temporary relocation to other TONHC facilities, including Sells Hospital, Santa Rosa Health Center, San Simon Health Center, and San Xavier Health Center. The NCM serves a vital role within the primary care team, assisting with community-based prevention and education activities, addressing social issues, and helping patients navigate the healthcare system.

The NCM works under the general supervision of the Clinical Director and functions with considerable independence in coordinating care teams and performing case management duties.

Responsibilities

• Work alongside the primary care team to assist individuals in accessing needed specialty medical care.
• Problem-solve obstacles to care for patients and families facing complex health problems in various socioeconomic contexts.
• Provide care coordination for persons with specialized and complex healthcare needs.
• Educate patients and families regarding recommended services, their benefits, risks, and alternatives.
• Facilitate scheduling of specialty appointments and arrange transportation.
• Follow up to verify appointment attendance and obtain visit, procedure, and test reports for medical records.
• Ensure the primary care team is aware of test results, treatments, and consultants' recommendations.
• Connect patients/families with appropriate community resources, including programs within and outside the Tohono O'odham Nation.
• Monitor progress, condition, and discharge plans for hospitalized TONHC beneficiaries.
• Provide information to primary care teams to ensure timely hospital discharge follow-up and reduce readmissions.
• Conduct chart reviews of patients followed by the NCM.
• Field inquiries regarding services available at TONHC.
• Follow up and attend scheduled clinic visits with patients.
• Assist with scheduling specialty appointments, including entering referrals and faxing documents for transportation.
• Communicate with patients and families in person, by phone, or by correspondence.
• Coordinate with specialty schedulers, Community Health Representatives, and Home Health Nurses.
• Attend community events to share information about TONHC services.
• Review area hospital admissions for TONHC beneficiaries and communicate relevant information to the primary care team.
• Compile listings of beneficiaries discharged or transferred from area hospitals.
• Coordinate weekly conference calls among Clinical Nurse Team Leaders, Social Work Services, and TON Home Health Nursing.
• Participate in TONHC care conferences to develop action plans for vulnerable individuals.
• Coordinate the Monthly Collaborative Meeting with community partners, including agenda creation and program presentations.
• Participate in Monthly Ambulatory Care Committee Meetings.
• Conduct patient assessments and provide case management and referrals for persons with chronic disease.
• Use evidence-based, culturally relevant education materials for patient self-management education.
• Document educational assessments, topics covered, and patient understanding in medical records.
• Develop goal-oriented plans for behavior change using motivational interviewing and adult learning strategies.
• Collaborate with multidisciplinary teams to develop and implement patient care plans.
• Monitor education and clinical interventions for individual clients and group data for performance improvement.
• Procure, organize, evaluate, update, and develop patient education materials.
• Maintain continuing education in chronic disease treatment, case management, and patient education.
• Assist in developing protocols and procedures according to relevant guidelines.
• Ensure all case management and patient education activities comply with patient confidentiality and HIPAA requirements.
• Participate actively in case management training.
• Maintain collaborative relationships with tribal and community partners.
• Perform other job-related duties as assigned.

Requirements

• Registered Nurse License.
• One year of clinical experience as a registered nurse, case management, or equivalent combination of training, education, and work experience.
• Unrestricted license as a Registered Nurse.
• Certification in Basic Life Support (BLS)/Cardio Pulmonary Resuscitation (CPR).
• Criminal background check and National FBI fingerprint check required upon hire.
• 39-month driving record check; must meet Tohono O'odham Nation tribal employer's insurance requirements to operate program vehicles (no DUIs or major traffic citations within the last three years).
• May require fluency in both the Tohono O'odham language and English as a condition of employment.

Skills

• Knowledge of Tohono O'odham traditions, language, history, geography, and culture.
• Knowledge of federal, state, tribal laws, regulations, and requirements.
• Knowledge of health-related issues, medical terminology, and health/child care education.
• Case management skills, including tracking, recall, identification of clinical needs, and communication.
• Strong working knowledge of chronic diseases (e.g., diabetes, cardiovascular disease, hypertension, depression, rheumatoid arthritis), including physiology, pathophysiology, clinical treatment, and patient self-management education.
• Knowledge of clinic policies and procedures, including quality control measures, universal precautions, and confidentiality issues.
• Ability to assess patients' learning and self-care needs and develop individualized care plans.
• Skills in adult learning, behavioral change, and lifestyle counseling techniques.
• Ability to accomplish goals through multidisciplinary teamwork.
• Effective verbal and written communication with patients, community members, and staff.
• Understanding of the social and cultural context of patients receiving care at TONHC.
• Knowledge of professional nursing principles, practices, and standards applied to case management.
• Ability to develop, implement, and evaluate comprehensive care management programs and patient/provider education.
• Ability to adjust teaching methods for unique patients, families, and special situations.
• Ability to perform clinical assessments, implement care, and document findings independently.
• Proficiency in Microsoft Word, MS Outlook, internet information acquisition, and accessing RPMS data.
• Ability to operate medical equipment, including blood pressure machines, glucose monitors, and sphygmomanometers.
• Ability to work extended hours, various schedules, and independently meet strict timelines.