RN Case Manager

Description Job Title RN Case Manager Location Fairbanks, AK, US Organization Name Health Services Job Summary Job Summary:

Case management services are provided across the lifespan, from birth to death. Case managers at TCC focus on the highest-risk patients within our population. Case managers assess the patient's plan of care and develop, implement, monitor and document the utilization of resources and the progress of the patient through their care. Delivery of appropriate, timely, and beneficial care for patients (IHS-Beneficiaries and Non-Beneficiaries) which promote quality and cost-effective healthcare outcomes, working within standards for case management practice and guidelines for reimbursement of chronic care management services. Case managers utilize case management systems to provide excellent care coordination, chronic disease management, and enabling patient services. Provide RN clinical services as needed to ensure an appropriate level of care and efficiency. Adhere to the TCC Ch'eghwtsen' model of service and guiding principle which requires providing timely and effective service along with the ability to interact with others in a way that inspires trust and demonstrates respect, compassion, and empathy.

Essential Functions Essential Functions:

This list is

ILLUSTRATIVE

ONLY and is not a comprehensive listing of all functions and tasks performed by incumbents. Incumbent(s) may not be required to perform all duties listed and may be required to perform additional, position-specific duties.

Representative Duties:

Under the general supervision of the Senior Case Manager, job incumbent will: 1. Utilizes the nursing process to maintain and manage a panel of patients referred to case management services by primary and specialty care medical providers. 2. Assesses patients' physical, psychological, social, spiritual, educational, developmental, cultural, and financial barriers to health. Reviews all available data and information from medical records and patient/family input to evaluate care planning needs and the patient's readiness to engage with services. 3. Formulates a plan of care, utilizing assessment data and patient, family, and health team input. Initiates a plan of care based on patient-specific needs, assessment data, and the medical plan of care. Sets goals with patients that are specific, measurable, realistic, and timely and that are desired by the patient and family. Considers the physical, cultural, psychosocial, spiritual, age-specific, and educational needs of the patient in the plan of care. Plans care in collaboration with members of the multidisciplinary team. Reviews and revises the plan of care to reflect changing patient needs that are based on evaluation of the patient's status. 4. Implements the plan of care through independent and collaborative direct patient care by in-person visits, telehealth, and by coordination of the activities of the health care team. Provides care based on physicians' orders and the nursing plan of care, standards of care, and regulatory agency requirements. Promotes continuity of care by accurately and completely communicating to other caregivers/providers the status of patients for whom care is provided. 5. Evaluates the patient's and family's response to care and teaching, and revises the plan of care as needed. Evaluates patient progress towards goals and expected outcomes in collaboration with other health care team members. Evaluates patient response and the effectiveness of patient teaching. 6. Documents assessment, planning, implementation and evaluation in the patient record. Documentation is legible, timely, and in accordance with policy. Documentation reflects objective/subjective data, nursing interventions, and the patient's response to treatment. 7. Provides telephone triage for patients on the case manager's panel. 8. Assists in discharge planning when needed from an inpatient facility or skilled nursing facility. 9. Follows case and quality management processes in compliance with regulatory guidelines and TCC procedures. 10. Provides care based on the best evidence available and may participate in research activities within clinical practice. May participate in facility shared leadership activities. Interacts and participates in the education, role development, and orientation of TCC personnel, patients, students, families, and visitors. Promotes/supports the growth of others through teaching and mentoring when appropriate. 11. Contributes to society through activities that lead to excellent patient outcomes through timely, effective, efficient, equitable, and safe care. Actively participates in the improvement of national nursing quality indicators and outcomes. Such activities may include participating in professional organizations. 12. Active participation in quality improvement projects and quarterly emergency drills.

Other Responsibilities:

1. Performs other duties and responsibilities as assigned. Tanana Chiefs Conference expects that all nurses will maintain the ability to perform basic clinical patient care skills. Clinical skills competencies will be demonstrated annually per the requirements of individual roles and as needed in support of general patient care services.

Minimum Qualifications Minimum Qualifications:

1. Registered Nurse license for the State of Alaska. Bachelor's degree in nursing preferred. 2. Three years of experience working as an RN in either an inpatient nursing department or in ambulatory care with demonstrated experience in needs assessment, discharge planning, care planning, patient education, or care coordination. Experience working in a tribal health organization is preferred. 3. Must be able to maintain strict confidentiality. 4. Must pass background check pursuant to federal Indian Child Protection and Family Violence Prevention Act requirements and State of Alaska DHSS background check.

Knowledge, Skills and Abilities:

1. General knowledge of case management practices, including familiarity with relevant products and services. 2. Clinical knowledge of common chronic health conditions, such as congestive heart failure or dementia. 3. Strong interpersonal, written and verbal communication skills with patients, physicians, and other stakeholders. 4. Demonstrated the ability to assess and respond to patient and family needs in a timely manner. 5. Strong critical thinking, prioritizing, and problem-solving skills. 6. Demonstrated teamwork experience. 7. Ability to work independently with minimal supervision. 8. Proficiency in using PC-based productivity applications and electronic health records. 9. Knowledge of quality management and improvement processes for the evaluation and improvement of the quality of clinical services. 10. Ability to establish and maintain effective working relationships with those contacted in the course of work, including service representatives and the general public. 11. Ability to obtain Alaska driver's license within 30 days of hire12. Ability to obtain provider BLS within 30 days of hire. Ability to obtain PALS and ACLS certification within 6 months of hire.

Supervision:

This position has no direct supervisory responsibilities.

Supervision Physical demands:

Lifting patients or equipment. Exposure to a variety of infectious and communicable diseases. Traveling from site to site (includes travel in small aircraft or boat), standing, and stooping for extended periods of time. Exposure to a variety of working environments, including rural village communities

Summation Summation:

This is a high public contact position including daily interaction with patients and health services staff. Position is obligated to follow Health Center, TCC and nursing principles to ensure safety of patients and staff. Must be able to work in a team or independently. Job incumbent must promote a courteous, professional and efficient public image to patients and referral providers/entities.