RN Case Manager

RN Case Manager

This position exists to support the organization's mission, vision, values, and strategic priorities by providing patient-centered care coordination and care management within a Medical Home model. The Registered Nurse Case Manager is responsible for providing care in accordance with evidence-based care coordination principles. The RN Case Manager assesses, plans, implements, coordinates, monitors, and evaluates care for assigned patients.

This position focuses on coordination of care for patients following emergency department visits, inpatient hospitalizations, specialty referrals, and identified care gaps to promote continuity of care, improve patient outcomes, reduce avoidable utilization, and support patient self-management. The RN Case Manager collaborates closely with providers, community resources, and the Senior RN Case Manager to ensure patients with complex, high-risk, or escalating needs receive appropriate interventions and support across the continuum of care.

This role also provides direct nursing care as required by patient needs, care transitions, or staffing demands, ensuring safe, high-quality, culturally responsive care while supporting efficient use of healthcare resources and a seamless patient experience.

Essential Functions:

The following functions are fundamental to the position and are required of all incumbents, with or without reasonable accommodation. These functions define the role and are not an exhaustive list of all duties.

• Functions as an RN Case Manager within a patient centered Medical Home, supporting coordinated, team based, whole person care across the lifespan (infant through older adult).

• Manages assigned patient panels using panel and population health strategies, including risk stratification, care gaps, and follow-up needs.

• Utilizes population health tools, registries, and reports to monitor preventive care, chronic disease indicators, utilization trends, and outcomes.

• Conducts comprehensive assessments to identify medical, behavioral, psychosocial, and functional needs impacting patient outcomes and care coordination.

• Develops, implements, and evaluates individualized care plans for assigned patients

• Coordinates care across providers, service lines, and community resources to ensure timely access, continuity, and appropriate utilization of services.

• Supports transitions of care by coordinating follow-up after emergency care, hospitalizations, specialty visits, or changes in level of care.

• Maintains care coordination and tracking systems to ensure follow-through on referrals, diagnostics, testing, and treatment plans.

• Provides patient and family education focused on condition management, prevention, navigation of the healthcare system, and self-management strategies.

• Collaborates with providers and interdisciplinary team members to address barriers to care, adherence challenges, and social drivers of health.

• Applies clinical judgment and case management principles to prioritize needs, problem-solve complex cases, and escalate concerns appropriately.

• Provides direct nursing care as required by patient acuity, staffing needs, or care transitions, including assessments, interventions, and patient education across the lifespan (infant through older adult).

• Participates in multidisciplinary care conferences for patients with complex, high-risk, or population-based needs.

• Documents care coordination, population health activities, patient education, and outcomes accurately and timely in the electronic health record.

• Participates in quality improvement, utilization management, population health, and performance improvement initiatives related to care coordination.

• Serves as a clinical resource to team members regarding care management workflows, panel management strategies, and best practices.

• Maintains compliance with infection prevention, safety, privacy, and regulatory requirements.

• Participates in required meetings, training, competency validation, and continuing education; performs related duties consistent with licensure and role.

Minimum Requirements:

• Graduate of a state-approved Registered Nursing (RN) program (Associate Degree in Nursing, diploma, or higher).

• Current Registered Nurse (RN) license in good standing

• Three (3) years of RN nursing experience or one (1) year of RN nursing experience and four (4) years of Licensed Practical Nursing experience

• Current Basic Life Support (BLS) certification.

Preferred Experience:

• Experience in patient-centered Medical Home, care management models, or interdisciplinary team-based care.

• Familiarity with referral management and care transition workflows.

How to Apply:

• Please submit your resume, including your complete work history. Ensure that your resume lists the month and year for each job (e.g., 01/2022 - 06/2026) so we can accurately assess your experience.
• Submit a copy of your Nursys licensure verification showing you meet the licensing requirements of the position.
• If you want to be considered for tribal preference, you must upload one of the following documents to verify eligibility:
• A certificate of enrollment bearing the tribe's official seal
• A tribal identification card
• BIA Form 4432
• Other official documentation issued by the tribe that verifies your enrollment
• If you are providing proof of descendancy, please provide either:
• An official letter bearing the tribe's seal that identifies you as a descendant of an enrolled member. This may include a letter confirming your descendancy, even if you do not meet the tribe's enrollment requirements.
• Documentation verifying your relative's tribal enrollment, as described above, along with birth certificates or other official records establishing your relationship to that enrolled member. For example, if the enrolled member is your grandparent, you may provide their enrollment documentation, your parent's birth certificate, and your birth certificate to establish the connection.
• If names differ across documents, please include supporting records, such as a marriage certificate or legal name-change document, to clarify the connection.
• *Please ensure all copies are clear and legible.

The GPTLHB is a tribal organization that follows tribal preference laws. Our policy is to give preference to qualified Indian/Tribal candidates over qualified non-native candidates in hiring decisions if all other qualifications are equal. Employment is contingent upon the outcome of all required criminal background checks.

Compliance with our Employee Health Procedure is a condition of employment. You are required to agree that you will comply with all job-related employee health screening and immunizations prior to your first day of employment. Jobs require that you have documentation that you have completed the following immunizations prior to your first day of employment: MMR (Measles, Mumps and Rubella, Varicella (Chicken Pox), Hepatitis B, Influenza, T-dap (Tetanus - Diphtheria - Pertussis), and COVID-19 vaccination is required.