Outpatient RN Case Manager (45100)

Under general supervision of the Purchased Referred Care (PRC) Nurse Manager, the Outpatient RN Case Manager provides utilization review and case management for patients referred for inpatient and outpatient care to other healthcare facilities and Durable Medical Equipment. Minimizes fragmentation in the healthcare system with a focus in coordinating transitions in care by tracking, monitoring and evaluating referrals and obtaining preauthorization when needed. Uphold the principles of WIHCC's Vision, Mission, and Value Statements. Maintains confidentiality of all privileged information at all times.

This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.

Essential Duties & Responsibilities:

• Maintains regular attendance and punctuality.
• Monitors external referral activities set by PRC, providing quarterly reports to ensure the department is on track to meet necessary measures.
• Provides case management for patients needing referred care for a range of modalities.
• Works with the patient, family and an interdisciplinary team; develops a care and service delivery plan based on needs of patient, available provider, and financial resources.
• Conducts appropriate concurrent and retrospective reviews on referred care to patients to determine the appropriateness of procedures, and the necessity of continued care.
• Determines medical necessity and appropriateness of level of care using Centers for Medicare & Medicaid Services (CMS) approved criteria for inpatient and outpatient referred care encounters.
• Checks the severity of illness, intensity of service and criteria on referred patients.
• Refers appropriate cases to the Chief Medical Officer for medical review.
• Screens all referrals for alternate resources and works closely with Patient Benefits Coordinators to maximize the use of alternate resources for referred care payment, protecting PRC funds for those patients who do not qualify for alternate resources.
• Determines if services are being delivered as planned and are meeting needs; reassesses, at appropriate intervals, to determine if the patient's condition or situation has changed, and revises goals and plan of services accordingly.
• Delegates and monitors patient referrals to Team Representatives, dependent on burden and staffing constraints.
• Serves as an advocate for the patient and their families.
• Provides in-service training to medical providers/PRC staff to enhance communication.
• Requires completion of tasks or duties assigned by a supervisor.
• Upholds all principles of confidentiality and patient care to the fullest extent.
• Adheres to all professional and ethical behavior standards of the healthcare industry.
• Adheres to WIHCCs Personnel Policies and Procedures, departmental policies, rules, and regulations.
• Interacts in an honest, trustworthy and dependable manner with patients, employees, visitors, and vendors.
• Possesses cultural awareness and sensitivity.
• Maintains compliance with all Human Resources requirements.
• Performs other duties as assigned.

Minimum Qualifications:


Bachelor's Degree in nursing required. Must be licensed as a Registered Nurse in Arizona or a Compact License State, the District of Columbia, or Puerto Rico. Certification in Case Management preferred. Three years clinical experience and one year of experience in utilization management, discharge planning, case management. Bilingual skills in English and Navajo language preferred. Must maintain a valid unrestricted and insurable driver's license. Must successfully pass a background investigation and maintain suitable requirements for a Child Care position. This position is considered as a Child Care position, which requires a satisfactory background check investigation and is subject to the requirements of the Indian Child Protection and Family Violence Prevention Act, as amended (henceforth referred as the ICPFVP Act).

Knowledge, Skills, Ability

• Knowledge of the Managed Care Model of healthcare services delivery including utilization review, the use of review criteria, clinical pathways and practice guidelines, discharge planning and case management.
• Knowledge of federal, state and private agency review requirements and regulations.
• Knowledge of and sensitivity to cultural and language differences.
• Knowledge of strong work ethics in the workplace.
• Knowledge of basic application of confidentiality.
• Knowledge of basic computer skills, e.g. Outlook, Word, Excel, PowerPoint.
• Skills in decision-making and independent judgment.
• Skills in creative problem solving and leadership.
• Ability to be flexible and use above average tact when dealing with people.
• Ability to be dependable in attendance and job performance.
• Ability to meet attendance, overtime (if necessary), and other reliability requirements of the job.
• Ability to accept and learn from feedback.
• Ability to effectively communicate both in written and verbal.
• Ability to provide exemplary customer service at all times.
• Ability to interact positively with others and possess great interpersonal skills.
• Ability to multitask and perform well under pressure.
• Ability to have self-confidence.
• Ability to be a great team player.
• Ability to accept and learn from supervisor/peer critique.
• Ability to be flexible and adaptable to the changing needs of the organization.

Physical Demands:

While performing the essential functions of this position, the employee is regularly required to walk, sit, use hands to handle and manipulate objects and equipment, reaches with hands and arms, and communicate effectively verbally and audibly. The employee frequently must stand, climb, balance, stoop, kneel, crouch, or crawl and may occasionally use taste or smell. The employee must occasionally lift and/or move objects weighing up to 25 pounds.


Work Environment:

Work is performed in an office setting or outdoor work environment with moderate noise levels. Work environment may involve exposure to physical risks, such as blood borne pathogens, hazardous chemicals, or operating potential dangerous equipment, and requires adherence to all safety protocols. Required work schedules may include evening, weekend, overnight shifts, extended hours, or irregular schedules as operational needs dictate.


As required by P.L. 93-638, absolute preference will be given to qualified Navajo applicants. If there is no qualified Navajo applicant, preference will be given to qualified American Indian applicants.