Nurse Case Manager
DWC Primary Care
The Nurse Case Manager is responsible for utilizing nursing processes in the development or care plans that include established goals, implementation of those plans, and monitoring and evaluation of an assigned case load in order to provide quality care to meet patients' clinical needs. The Nurse Case Manager will coordinate preventative health care services, assist in chronic disease management, coordinate referrals and deliver professional nursing services.
Collaborate with care team members to develop a treatment plan and goals.
Evaluate a plan of care and use of resources and arrangement of services to reach outcomes in specific time frames.
Coordinate resources and services in response to individual healthcare needs.
Center services around patient, foster patient self-managed care.
Utilize clinical pathways in assessment and monitoring of clients and healthcare delivery.
Review, analyze, and process referrals from providers.
Contact health care providers for assessments of the clinical status of the patient
May analyze clinical reports utilizing approved standards and document results attained
Coordinate preventative health care services, such as: well child checks, prostate exams, pap smears, colorectal screenings, etc.
Assist in chronic disease management such as: chronic kidney disease, congestive heart failure, rheumatoid arthritis, etc.
Serve as first clinical point of contact within their assigned provider's panel
Coordinate patient care issues: prior/pre-authorization, assisting with appointments, medication refills, and obtaining up-to-date medical records in the electronic wellness record
Arrange and track the progress of referrals and outcomes of care. Provide status report to providers on current and outstanding referrals. Is available as a primary link for other case managers and discharge coordinators to facilitate follow through for care coordination.
Work collaboratively by building bridges and creating rapport with all team members within the organization, the Alaska Native Tribal Health System, and other referral agencies, functioning as a liaison between specialty providers, and patients.
Attend staff meetings for information sharing, continuing education activities, and participate in continuous improvement efforts as required.
Knowledge and experience working with Alaska Native/American Indian people (Preferred)
Perform other duties as assigned.
Working Conditions Lifting Requirements
Sedentary work – Exerting up to 10 pounds of force occasionally, and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.
Stand or Sit (Stationary position)
Walk (Move, Traverse)
Use hands/fingers to handle or feel (Operate, Activate, Use, Prepare, Inspect, Place, Detect, Position)
Climb (stairs/ladders) or balance (Ascend/Descend, Work atop, Traverse)
Stoop, kneel, crouch or crawl (Position self (to), Move)
Talk/hear (Communicate, Detect, Converse with, Discern, Convey, Express oneself, Exchange information)
See (Detect, Determine, Perceive, Identify, Recognize, Judge, Observe, Inspect, Estimate, Assess)
Hazards and Atmospheric Conditions
Category II – Normal routine involves no exposure to blood, body fluid or tissue, but exposure or potential for exposure may occur
Equipment and Tools
List Equipment used for job: Stethoscope, thermometer, pulse oximetry, sphygmomanometer, computer, telephone, weight scale, and EKG machine.
List Tools:Drives KIT or Personal Vehicle:Other:
Comments: Travel may be required for training
Associates or Bachelors degree in nursing required
3 years recent clinical experience preferred
RN or LPN degree required
Strong analytical and critical thinking skills
Attention to detail
Good listening skills to best understand both the medical and social needs of patients
Strong oral and written communication skills
This Job Description reflects Kenaitze Indian Tribe's best effort to describe the essential functions and qualifications of the job described. It is not an exhaustive statement of all the duties, responsibilities or qualifications of the job. This document is not intended to exclude an opportunity for modifications consistent with providing reasonable accommodation. This is not intended to be a contract.
Keywords: LPN, Nurse, Licensed Practical Nurse, Registered Nurse, Bachelor's,