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. Other duties include assisting with the planning and implementation of community-based prevention and education activities.

Responsibilities

• Works alongside the primary care team to assist individuals in promptly accessing needed specialty medical care.
• Problem-solving multiple obstacles to care for patients and families face when dealing with complex health problems in various socioeconomic contexts.
• Provide care coordination for persons with specialized and complex healthcare needs.
• Educate patients and families regarding the recommended services, their expected benefits, risks, and alternatives.
• Facilitates scheduling of the specialty appointments and ensures transportation to and from is arranged.
• Follows up to verify appointment attendance and obtain visits, procedures, and test reports for the patient's medical records.
• Ensure the primary care team is aware of test results, treatments, and consultants' recommendations.
• Connects the patient/family with appropriate resources by referral to community services for which they may be eligible, including programs within and outside the Tohono O'odham Nation.
• Monitor progress, condition, and discharge plan to TONHC beneficiaries hospitalized in and outside Tucson, Casa Grande, and Phoenix facilities.
• Provides information to primary care teams to ensure the client receives hospital discharge follow-up in a timely manner to decrease hospital readmissions.
• Conducts chart reviews of patients whom NCM follows.
• Fields inquires via incoming calls regarding services available at TONHC.
• Follow-ups and attends scheduled clinic visits with patients followed by NCM.
• Affixes transportation for medical appointments.
• Perform task-oriented work based on patient needs.
• Communicate with patients and families in person, by phone, or by correspondence.
• Frequently communicates with specialty schedulers within the TONHC referral network and with local community partners.
• Communicates with Community Health Representatives and Home Health Nurses to contact difficult-to-reach patients and families and obtain useful clinical reports.
• Attends community events to share information about services available to TONHC.
• Reviews area hospital admissions via remote access for TONHC beneficiaries and communicates relevant information to the primary care team.
• Compile a listing of beneficiaries discharged from area hospitals or transferred to area hospitals from the Sells ER or TONHC ambulatory clinics.
• Coordinate weekly conference calls among all Clinical Nurse Team Leaders, Social Work Services, and TON Home Health Nursing to improve coordinated continuity of care and reduce risk of hospital readmission.
• Participates in TONHC care conference – a collaborative meeting with Adult Care, Senior Services, Behavioral Health, Home Health Nursing, and Community Health Representatives putting action plans in place for vulnerable individuals followed by the various programs.
• Coordinates the Monthly Collaboratively Meeting with our Community Partners, including creating an agenda and arranging a program presentation to update attendees about local services to community members and scheduling the meeting by the video conference to all TONHC clinical sites.
• Participate in the Monthly Ambulatory Care Committee Meetings.
• Conducts patient assessments and provides appropriate case management and referral for persons with chronic disease.
• Use reliable, evidence-based, culturally relevant education material or curricula for providing comprehensive patient self-management education.
• Documents educational assessment, topics covered, and evaluation of the patient's understanding in the medical record.
• Uses patient and family education codes in documentation; develops a process to assist the patient with establishing a goal-orientated plan for behavior change.
• Use teaching strategies that include various approaches and methods that incorporate theories and concepts related to adult learning, readiness for change, empowerment, and motivational interviewing.
• Collaborates with the multidisciplinary team to develop and implement a patient care plan that meets relevant standards of care, evaluates the educational process and clinical outcomes, and makes appropriate referrals.
• Uses case management techniques to monitor education and clinical interventions for individual clients, routinely monitors group data for performance improvement activities.
• Procures, organizes, evaluates, updates, and develops patient education materials for health care professionals, patients, and family members.
• Maintains continuing education in chronic disease treatment, case management, patient education, teaching strategies, behavior change, and other topics related to the scope of work.
• Affords assistance in the development of protocols and procedures according to relevant guidelines.
• Affords assistance in the development of a realistic, measurable work plan for project activities.
• Ensures that all case management and patient education activities performed are with the utmost attention to patient confidentiality and HIPAA requirements.
• Participates actively in case management training.
• Maintains collaborative relationships with members and tribal and community partners.

Qualifications

• Registered Nurse License.
• One year of clinical experience as a registered nurse, case management, or an equivalent combination of training, education, and work experience that demonstrates the ability to perform the duties of this position.

Skills

• Knowledge of the Tohono O'odham traditions, language, history, geography, and culture.
• Knowledge of applicable federal, state, tribal laws, regulations, and requirements.
• Knowledge of health-related issues, medical terminology, and health and child care education.
• Knowledge of case management skills such as tracking, recall, identification of clinical needs, and communication.
• Strong working knowledge of chronic disease (including but not limited to: diabetes, cardiovascular disease, hypertension, dyslipidemia, depression, and rheumatoid arthritis); physiology, and pathophysiology, multidisciplinary clinical treatment, TONHC clinical care policies, medication protocols, and patient self-management education.
• Knowledge of clinic policy and procedures, including but not limited to quality control measures for blood glucose monitoring equipment, universal precautions, patient education standards, and confidentiality issues.
• Ability to identify essential case management functions and provide needed intervention.
• Ability to assess patients' learning self-care and behavior change needs and develop and implement individualized care plans.
• Knowledge in adult learning behavioral change and lifestyle counseling techniques, the ability and skill to enhance learning and behavior change.
• Ability to accomplish targeted goals through multidisciplinary teamwork.
• Ability to communicate effectively, verbally and in writing, with patients, community members, professional and non-professional staff.
• Skills that integrate an understanding of the social and cultural context and needs of the people who receive care at TONHC.
• Knowledge of professional nursing principles, practices, procedures, standards of care, and concepts applied to case management.
• Ability to independently develop, implement, maintain, and evaluate a comprehensive care management program and patient and provider education.
• Ability to independently adjust teaching methods for unique patients and families, paraprofessionals, professionals, and special situations.
• Ability to independently perform a clinical assessment, implement needed care, and report and document findings.
• Ability to use computer programs such as Microsoft (MS) Word, MS Outlook, internet information acquisition, and accessing RPMS data.
• Ability to operate medical equipment includes blood pressure machine, Accu-check and glucose machine, sphygmomanometer, and other related equipment.
• Ability to work extended hours and various work schedules.
• Ability to work independently and meet strict timelines.
• Ability to operate a department vehicle.

Benefits

Not specified.

Pay

$94904.99 per year

Schedule

Not specified.