RN Case Manager

You will be asked to provide three (3) professional references and the past seven (7) years of education and employment history. The application is 9 steps and typically takes 9-15 minutes.

This description is intended to describe the essential job functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned, and management may, with or without notice, add or change the duties at any time.

Notice to Applicants: All applicants offered employment with Chugachmiut will be subject to a background investigation. Offers of employment are contingent on the successful completion of a background investigation conducted in accordance with Chugachmiut policy and Public Law 101-630. Every offer of employment with Chugachmiut will be made contingent on a background investigation. The nature and extent of the investigation will depend on the job duties of the position for which an offer is made.

USE OF INFORMATION OBTAINED IN A BACKGROUND INVESTIGATION

Information obtained from a background investigation will be considered for employment purposes as permitted by federal and state law and in accordance with Chugachmiut’s policy. Information will be reviewed to determine:

• Whether an individual made false statements or material omissions on an application for employment or during an interview;
• Whether an applicant or employee, based on the job duties of the position in question, poses a threat to security and/or employee safety in the workplace; and
• The likelihood of an applicant or employee being successful and productive on the job.

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RN Case Manager

Summary:

This position works in partnership with the integrated care team to deliver clinical support services, health education, and care coordination for rural communities within the Chugachmiut Service Area.

The RN Case Manager is responsible for coordinating clinical quality improvement initiatives, patient-centered medical home activities, and care coordination efforts across the region. In collaboration with the medical care team, the RN Case Manager facilitates care coordination, documents and maintains individualized care plans, reconciles medications, and conducts follow-up and recall activities. Emphasis is placed on preventive care services and timely follow-up for individuals with acute and chronic conditions to support continuity of care and improved health outcomes.

Major Responsibilities:

Creates, develops, and nurtures culturally appropriate interactions and connections with each other, patients, and the community.

Initiates coordination of Case Management services upon receipt of message/referral and closes the case when all care services have been coordinated for the patient. Participates as an integral member of the health division in the provision of medical services by collaborating with other health professionals to provide Chugach Region community member’s complete and comprehensive care.

Continually strives to improve patients' experience and quality of care by focusing on key leverage points of optimal patient access, continuity, team-based care, clinical information systems, patient self-management, and community engagement.

Monitors the quality of care delivered and provides and receives feedback on the quality of care being delivered to ensure regulatory standards and policies are met as they apply to Chugachmiut’s health clinics.

Works together with the integrated care team and patient/family with a focus on maximizing health outcomes. Participates in care conferences for patients.

Acts as a patient advocate, helping them understand their healthcare options and connecting them with appropriate resources and services.

Applies best practice model to identify, incorporate, or develop best practices for panel management. Collaborates with other teams to share and establish best practices for the clinic and division.

Manages patient's health maintenance, utilizes data to assess and monitor panels, meeting or exceeding clinic expectations for health maintenance standards.

Integrates quality, safety, efficiency, and cost-effectiveness factors in planning, delivering, monitoring, and evaluating patient care, promoting the most effective and efficient use of human and financial resources.

Utilizes patient-based tracking systems or clinical databases to track, monitor, and ensure the appropriate follow-up of patients. Utilizes other software packages and applications for ordering, scheduling, and tracking patient care.

Works closely with our tribal healthcare partners across the state to coordinate care across the continuum for our patients. Acts as a liaison between referral provider and PCP, supports health care providers, schedules diagnostic tests, clinic appointments, and provides support as needed.

Creates rapport within the integrated care team and members of the organization.

Responds to emergencies and coaches/mentors all clinical team members to build capability and competency.

Collaborates with the patient, family, and other healthcare providers to formulate the plan of care and goals, as well as assists the patient and family in identifying and obtaining the appropriate and available services for their healthcare needs.

Interacts with and contributes to the professional development of peers and others practicing in a Shared Governance model of nursing practice.

Makes decisions and takes actions on patients' behalf, is determined ethically, and delivers care in a nonjudgmental and nondiscriminatory manner that is sensitive to patient diversity, preserving patient autonomy, dignity, and rights.

Notifies providers of patient needs as identified promptly and follows up on specialist recommendations with PCP as needed.

Consults a PCP when any unfamiliar, uncommon, or unstable condition arises.

Performs nursing assessments, interventions, and evaluations.

Provides services via telehealth.

Educates patients in a wide variety of health care subjects such as disease prevention, lifestyle issues, basic health care maintenance, and self-administration of medications.

Performs patient follow-up, including notifying patients of laboratory results, medication refills, scheduling referral appointments, maintaining charts and records, and responding to patient telephone calls.

Travels to remote village clinics as needed to provide direct care.

Provides nursing support to include patient intake, vital signs, vaccine/medication administration, and assists with procedures.

Utilizes the ANA Scope and Standards of Practice and Code of Ethics for Nurses.

Effectively communicates with patients and families in a culturally sensitive manner.

Assists with Performance Improvement initiatives.

Serves as a resource on case management for Chugachmiut Health Services.

Initiates and develops in-service training to keep staff updated on issues of health wellness, disease management, and coordination of care.

Attends and participates in clinical service team meetings, staff meetings, and other committee efforts as appropriate.

Prepares patient education materials as needed.

As requested, participate in and/or provide health education opportunities for patients and communities in conjunction with other Chugachmiut staff. Activities may include providing health education and screening services at schools, health events, and other community events.

Ensures the maintenance of timely and accurate patient records to reflect each patient's health status, risk factors, plan of care, and safeguards the confidentiality of patient records.

Complies and adheres to established compliance, privacy, integrity, and Chugachmiut’s policies and practices, applicable ethical standards, laws, regulations, rules, code of conduct, procedures, and professional standards.

Follows established protocol for patient referrals within and outside the Alaska Tribal System.

Works with the Purchased and Referred Care Program (PRC) to prioritize the medical needs of patients and to ensure financial stability.

Assists in managing outpatient referrals.

Complies with statutes and regulations from the State of Alaska, Division of Occupational Licensing, for Registered Nurses.

Conforms to safety policies and general housekeeping practices.

Demonstrates sound work ethic, flexibility, and shows dedication to the position.

Demonstrates a positive attitude, is respectful, and possesses cultural awareness and sensitivity toward patients and co-workers.

Keep customer service and the organization's mission in mind when interacting with all patients, co-workers, and others.

Expected to be prepared to start shift on time, meet attendance standards, and work the hours necessary to perform the job's essential functions.

Embraces, supports, and promotes the core values of respect, integrity, trust, compassion, and quality, which align with Chugachmiut's Mission and Vision through their actions and interactions with all patients, staff, and others.

Conforms to Chugachmiut policies, strict employee confidentiality, and patient privacy regulations (HIPAA & 42 C.F.R. Part 2).

Performs other duties as assigned or required.

Education Requirements:

Alaska license in good standing as a Registered Nurse

Current BLS certification required

Experience in primary care services preferred

Experience in a rural health care setting preferred

Experience in a tribal health setting preferred

Experience with Oracle Health, AFHCAN, and Zoom preferred

Physical Environment:

The following demands are representative of those that an employee must meet to perform the essential functions of this job successfully. The position requires the ability to sit for a long period of time, a normal range of hearing and eyesight, eye-hand coordination, and manual dexterity to operate office equipment such as a computer keyboard, photocopier, telephone, and calculator and may be required to lift approximately 30 pounds. May be exposed to infectious diseases or hazardous equipment. May be exposed to extreme weather conditions. Travel to remote locations by boat, snowmobile, ATV, or small plane is required, and employee must be willing and able to travel.

Hours of Work:

Work is performed during current business hours, with the potential to work extended hours during the week and/or weekend. Shifts of 7.5 hours or more per day will include a 1-hour unpaid lunch. Chugachmiut maintains a drug and alcohol and non-smoking work environment.