Registered Nurse (Chronic Care Case Manager)

Chronic Care Case Management RN

**IF YOU PREVIOUSLY APPLIED FOR THIS POSITION, YOU DO NOT NEED TO RE-SUBMIT YOUR APPLICATION**

Position Summary: Under the general supervision of the Chronic Care Case Management RN Supervisor (CCCMRNS), the Chronic Care Case Management RN will perform telephonic and disease management assessments to empower patients to better understand their illness and to self-manage their conditions. This job class is treated as FLSA Exempt.

Essential Functions: Essential functions may vary among positions and may include the following tasks, knowledge, abilities, skills and other characteristics. This list of tasks is ILLUSTRATIVE ONLY and is not intended to be a comprehensive listing of tasks performed by all positions in this classification.

• Provides assessment, disease management, education, training, and other clinically based activities to coordinate care among providers, patients and the community
• Makes adequate contact with the patients with a focus on behavioral goal setting and patient-centered support planning. Identifies patient resource needs, provides information on possible resources and referrals to patients
• Collaborates with other health care providers to review actual and proposed medical care and services against established coverage guidelines review criteria
• Manages network participation, care with specialty networks, care with medical providers, and transfers to alternate levels of care using knowledge of benefit plan design
• Recommends services for patients using care alternatives available in the community. Identifies potentially unnecessary services and care-delivery settings and recommends alternatives by analyzing clinical protocols
• Examines clinical programs information to identify members for specific case management and/or disease management activities or interventions by using established screening criteria
• Conducts admission reviews, post-discharge calls, and discharge planning
• Conduct thorough assessments of patients' health status, medical history, and current treatment plans to create individualized disease management plans
• Educate patients and their families about their specific chronic condition, including symptoms, treatment options, and self-care practices
• Monitor and evaluate patients' response to treatment, making necessary adjustments to their care plans as needed
• Collaborate with other healthcare professionals, such as physicians, pharmacists, and social workers, to ensure coordinated and holistic care for patients
• Provide ongoing support and counseling to patients and their families, addressing their concerns, providing emotional support, and promoting self-management techniques
• Assist in organizing and conducting educational programs and workshops for patients, caregivers, and the community to raise awareness and improve disease management practices
• Maintain accurate and up-to-date medical records and documentation of patient assessments, care plans, interventions, and outcomes
• Stay updated with the latest research, advancements, and best practices in disease management to deliver evidence-based care
• Collaborate with insurance providers and case managers to ensure proper reimbursement for services provided and facilitate smooth transitions of care
• Participate in quality improvement initiatives and contribute to developing and implementing evidence-based protocols and guidelines for disease management
• Multidisciplinary Care Coordination: Follows established policies, procedures and standing orders.
• Follows patients through the care continuum and collaborates with other members of the health care team to ensure continuity of care and implements the agreed plan of care.
• Consults with physicians and other health care providers regarding patient specific clinical, social and behavior health related issues and educational needs.
• Facilitates timely and appropriate referrals and fosters positive relations with community providers and partners.
• Participates in patient care conferences including but not limited to hospital, clinic, home health care, SNF/LTC, etc as well as specialty team meetings as required by Health Plans for individual groups of members and/or eligibility status (i.e Special Needs, Individual Education Plan, Disability, etc) by preparing and completing required documents.

Knowledge, Skills, Abilities and other Characteristics:

• Knowledge of the history, culture, laws, rules, customs and traditions of the SRPMIC.
• Knowledge of the purpose, current issues, projects, organization, policies, and employee responsibilities of the division to which assigned.
• Knowledge of theory, principles and scope of practice for a Case Manager RN
• Knowledge of federal, state, and agency laws and regulations governing professional nursing.
• Knowledge of health systems and disease processes.
• Knowledge of medical, public health and social service resources available to Native Americans including, but not limited to, Indian Health Service, Medicare, Medicaid, ALTCS, SSI, etc.
• Strong verbal and written communication skills.
• Experience with E.H.R's and community resources.
• Focused customer service skills and excellent problem-solving skills.
• Ability to use critical thinking and to problem solve in a professional manner.
• Desire to work collaboratively and proactively with healthcare teams and other hospital-based interdisciplinary teams.
• Excellent communication skills to effectively educate, counsel, and advocate for patients and their families.
• Empathy and compassion to provide emotional support and address the needs of patients.
• Proficiency in using electronic health record systems and other healthcare software for accurate documentation and information retrieval.
• Strong organizational and time management skills to prioritize tasks and manage medical services referrals effectively.
• Knowledge of CMS, AHCCCS, and commercial payer requirements as well as care coordination and resource management in ambulatory care settings.
• Leads and proactively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff.
• Skill with verbal and written communication and ability to communicate effectively with a wide range of people, correctional facility staff and health professionals.
• Skill applying and interpreting federal, state, and agency laws and regulations governing practical nursing.
• Ability to establish and maintain positive working relationships with colleagues, subordinates, supervisors, health care professionals, Tribal officials, detainees and representatives of resource agencies.
• Ability to incorporate cultural differences, health beliefs and learning styles.
• Ability to maintain confidentiality.
• Ability to operate a variety of standard office equipment including cellular phones, photocopiers, FAX machines, calculators and personal computers including MS Office.

Minimum Qualifications:

• Education and Experience:
  • Active unrestricted AZ Registered Nurse license from an accredited college or university required.
  • Bachelor of Science in Nursing (BSN) degree
  • Minimum of 1-2 years of experience including Primary Care Case Management preferred
  • Two (2) years of clinical nursing experience in acute care or outpatient setting preferred
  • Certification as a Certified Case Manager (CCM) preferred or ability to obtain within 18 months of hire.
  • Experience working with Native American Communities preferred.
• Equivalency: Any equivalent combination of education and/or experience that would allow the candidate to satisfactorily perform the duties of this position, will be considered.
• Underfill Eligibility: An enrolled Community Member whom closely qualifies for the minimum qualifications for a position may be considered for employment under SRPMIC Policy 2-19, Underfill.

Special Requirements: Employment is contingent upon successful completion of an extensive background check and drug screening.

• Special Requirements:
  • Employees in, and applicants applying for, jobs providing direct services to children are subject to the "Community Code of Ordinances", Chapter 11, "Minors", Article X. "Investigation of Persons Working With Children".
  • New hires in clinical roles must present valid BLS certification (Healthcare Provider BLS for clinicians) prior to the first day of patient care.
  • Ensures all patient information is kept confidential and complies with Health Insurance Portability and Accountability Act (HIPAA) regulations and SRPMIC HHS policies and procedures.

Prior to hire as an employee, applicants will be subject to drug and alcohol testing. Will be required to pass a pre-employment background/fingerprint check.

"SRPMIC is an Equal Opportunity/Affirmative Action Employer" Preference will be given to a qualified: Community Member Veteran, Community Member, Spouse of Community Member, qualified Native American, and then other qualified candidate.