Alaska Native Tribal Health Consortium has a hiring preference for qualified Alaska Native and American Indian applicants pursuant to P.L. 93-638 Indian Self Determination Act.

Summary:
Under administrative/Director supervision, oversees the RN Case Managers, manages the team schedule, day to day operations, completes annual and periodic evaluations for the RN Case Managers, collaborates with the specialty and acute care team, medical providers, post-acute care team representative, the patient’s primary care manager, the patient, and family to identify and manage proactive care planning and interventions to promote patient wellness and satisfaction during continuum of care transitions.

Responsibilities:
Manages the hiring, training, and evaluation of RN Case Managers. Oversees the daily operations of the RN Case Managers including: scheduling, assignments, and daily operations. Identifies care management patients by accessing Emergency Department (ED) or inpatient services and establishes personal contact within 24 hours of inpatient or ED referral. Creates and coordinates a focused transitional and discharge plan of care for chronic, high-risk patients based on initial nursing assessment. Completes assessment in collaboration with the patient, his/her family, direct care providers, primary care manager, post-acute care providers, community agencies, patient housing providers, and other staff as needed. Facilitates/conducts concurrent medical record review to measure patient progress against goals established for discharge and RNs documentation accuracy and compliance. Prepares and presents cases for discussion at scheduled meetings. Expedites proper sequencing and scheduling of interventions, treatments, and procedures in accordance with the patient’s need during inpatient care. Manages continuity of effective and timely communication between patient and providers. Assists RN Case Managers with communicating patient needs with anticipated site coordinator as necessary. Reviews transition/discharge plan to ensure the patient and his/her family understand the plan including medications and discharge needs. Coordinates with pre-authorization and financial counselors for acute and post-acute care as needed. Identifies and communicates any problems or issues that affect patient flow, patient satisfaction, and patient safety, length of stay management, or outcomes to the department Director and/or appropriate key stakeholders. Works with acute and primary care multi-disciplinary care team to prevent readmissions; identifies and communicates relevant information and facilitates care conference(s) as needed. Displays innovation in problem solving and critical thinking. Personally upholds the ANTHC Behavior Standards, and encourages the SW Case Managers to do the same. Assists leadership in Transitional Care Program development and continuous improvement through measurement and feedback of appropriate outcome based processes and strategies. Actively participates in developing program structure, tools, procedures and communication strategies. Recommends changes for process improvement in program policies and operations to meet objectives. Performs other duties as assigned or required.