Case Manager - Registered Nurse

Department:Primary Care

Reports to:Chief Medical Officer (CMO)

FLSA Status:Exempt

Type of Position:Full-Time

Revised Date:09/30/2024

MISSION & VISION STATEMENT:

The Kewa Pueblo Health Corporation (KPHC) is established for the purposes of carrying out the vision and mission of the Santo Domingo Health Center (SDHC). The MISSION of KPHC is:  “ENSURING HEALTH & WELLNESS THROUGH EXCELLENCE IN HEALTHCARE WITH RESPECT FOR CULTURE” and the VISION OF KPHC is:  “HEALTHY PEOPLE, HEALTHY COMMUNITY, and HEALTHY LIFESTYLE”.

POSITION PURPOSE:

The Case Manager/RN is responsible for providing relevant case management, social, and supportive services to the community of Santo Domingo and its adjacent service unit as it relates to the internal functions of the clinical department and branched services (internal and external) such as and not limited to:  Outpatient Department, Purchased/Referred Care (PRC), Patient Registration/Benefits, and the SDHC Administration.

PERFOMANCE EXPECTATIONS:

In performance of their respective tasks and duties all employees of the Kewa Pueblo Health Center are expected to conform to the following:

• Fully uphold all principles of confidentiality and patient care.
• Adhere to all professional and ethical behavior standards of the healthcare industry.
• Interact in an honest, trustworthy and dependable manner with patients, employees and vendors.
• Possess cultural awareness and sensitivity.
• Maintain a current insurable driver’s license.
• Comply with all Kewa Pueblo Health Corporation and Santo Domingo Health Center policies and procedures, as well

ESSENTIAL DUTIES, FUNCTIONS & RESPONSIBILITIES:

Case Management:

• As a case manager you will collaborate with providers and clinicians.  You will network with outside entities to fulfill follow-up care for patients within their treatment plans.
• Collaborates with patient & family members in the development, implementation, and evaluation of patient plan of care. Integrates cultural and age-specific differences when developing, implementing, and evaluating patient’s plan of care.
• Case manager will assess, plan, implement, coordinate, monitor, and evaluate the options and services required to meet a client’s health and human services needs.
• Provide a culturally sensitive care plan focused on the needs and values of the population served.
• Identifies goals and case management actions required to meet diagnosis-specific goals. Develops a care plan that addresses physical, psychological, social, and rehabilitative discharge planning to meet those goals.
• Will collect and or update socio-demographic information on the patient.
• Will define immediate needs: Socio/Psycho-social needs and create a plan of care.
• Will work with Purchased Referred Care (PRC) in out of network claims, appointment, and procedures.
• Will establish a needs assessment as part of the intake stage.
• Will collaborate with other departments/professionals in developing a case management plan:

•    Monitoring
•    Supervision
•    Reassessment
•    Revision

• Defines patient resource needs: Provide management of Care Team’s Care Transitions program for patients discharged from an inpatient setting.
• Educate, empower, and engage patients in following their treatment plan.
• Follow-up on patient status: Treatment plan and visits.
• Incorporates quality improvement measures in improving nursing care performance.
• Provides ongoing training to the nursing administrative team on evidence-based practices in case management.
• Knowledge of current function, services, staffing and cost in an ambulatory care setting and inpatient care setting to accomplish operational plans.
• Educates patients or providers on the five (5) PRC eligibility factors.
• Serves as a stakeholder and spokesperson for the organization during important events.
• Reports evidence-based data to befit organization’s practices for best care.
• Ensure compliance to federal, state, and local policies and regulations as indicated.
• Maintains nursing licensure and clinical trainings (CEU’s, nursing education competencies).
• Educate via Departmental and Intra/Interdepartmental training or in-services.
• Will keep record and report metrics to senior leadership, providers, and patient community.
• Performs all other duties as assigned.

Personal Contacts and Inquires:

• Communicates with patients to coordinate medical appointments based on referrals and follow up treatment plans as continuity of care.
• Knowledge of the principles of growth and development over life span and possess the ability to assess data reflective of patient’s status and interpret patient information relative to their age specific needs. Ability to provide the care needed as described in the nursing department’s policies and procedures manual.
• Knowledge of professional nursing theory and practices through completion of professional nursing education programs and supplemented by years of professional nursing experience.

MINIMUM MANDATORY QUALIFICATIONS:

Education:

• Associate Degree in Nursing, RN license; Basic Life Support (BLS) certification; CPR/First Aid certification or must obtain within 30 calendar days of hire.

Experience:

• Three (3) years nursing experience, preferably, in a clinic or hospital setting, performing case management services and or utilization review.

Licensure:

• Current New Mexico Registered Nurse License and in good standing with the Board of Registered Nurses.

Mandatory Knowledge, Skills and Abilities:

• Understanding of medical terminology, gross anatomy and physiology.
• Ability to read, analyze, and interpret medical reports, professional journals, technical procedures

• Excellent computer skills and knowledge of software and applications associated with general office administration, excellent communication skills, both written and verbal; able to work shift schedule.
• Must be familiar with PRC Applications/Notification, eligibility, denial/approval and appeal process. Able to gather information from face-to-face interviews or by telephone with patients, private contracted or open market providers such as Medical Records departments, Business Office personnel.
• Thorough knowledge of Privacy Act of 1974, which mandates that the incumbent shall maintain complete confidentiality of all medical records and patient files and other sensitive information that comes to his/her attention.
• Working knowledge of Medicare/Medicaid, Social Security Administration, County, State and Tribal health programs and other related agencies policies and procedures and the knowledge to apply other benefits should one has been exhausted.
• Knowledge of Purchased/Referred Care program and activities including awareness and understanding of the purpose, objectives, commitments and priorities to perform both recurring and special assignments.
• Knowledge and skill in using EHR/RCIS.

PREFERRED QUALIFICATIONS:

• Bilingual skills in English and the Keres native language.
• Bachelor of Science degree in Nursing.
• Case Management or Diabetes Case Management Certification (CMGT-BC and/or BC-ADM).
• Experience performing customer service in a medical setting.
• Prior experience working with Indian Health Services (IHS), a Tribe or Tribal Organization.

WORK ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the primary functions of this job. Normal office conditions exist, and the noise level in the work environment can vary from low to moderate. In addition, work is performed in a clinic outpatient and/or field setting and may include exposure to infection, disoriented patients, and communicable disease. This position may be exposed to certain health risks that are inherent when working within a health center facility.

PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the primary functions of this job. While performing the duties of this job, the employee may be required to frequently stand, walk, sit, bend, twist, talk and hear. The employee must occasionally lift and/or move up to 50 pounds.

MENTAL DEMANDS:

There are several deadlines associated with this position. The employee must also multi-task and interact with a wider variety of people on various and, at times, complicated issues. 

OTHER:

All employees must fully uphold all principles of confidentiality and patient care. This position has access to sensitive information and a breach of these principles will be grounds for immediate termination.

Disclaimer:  The information on this position description has been designed to indicate the general nature and level of work performance by employees in this position.  It is not designed to contain, or be interpreted as, a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this position. Employees will be asked to perform other duties as needed.

Salary Range:  $90,954.00 - $136,431.00