RN Case Manager Advanced

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 assesses the patient's plan of care and develops, implements, monitors and documents the utilization of resources and 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 health care 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 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: This list is ILLUSTRATIVE ONLY and is not a comprehensive listing of all functions and tasks performed by incumbent(s).

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 patients' 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 are. Plans care in collaboration with members of the multidisciplinary team. Reviews and revises the plan of care to reflect changing patient needs 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's 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 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 inpatient facility or skilled nursing facility.

9. Follows case management 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 growth of others through teaching and mentoring when appropriate.

11. Identifies areas of need for quality improvement and actively designs and implements quality improvement projects to better meet the needs of TCC patients and improve health outcomes.

12. Serves as a subject matter expert in assessing the needs of chronic and high risk patients and planning appropriate care. May assume responsibility for orienting and training nurses new to the role of RN Case Manager.

13. Possess the knowledge, skills, and ability to serve as the Acting Senior Case Manager when needed and to provide both clinical and administrative supervision for other members of the case management team.

14. 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.

Other Responsibilities:

15. 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:

1. Registered Nurse license for the State of Alaska; Associates or Bachelor's degree from accredited college or university with major course work in nursing. Masters in nursing is preferred.

2. Five years of experience in case management with a minimum of 6 months of experience working in a tribal health organization.3

. Certification in Case Management, Care Coordination, Care Transitions (or similar) is preferred.

4. Must be able to maintain strict confidentiality.

5. Must pass background check pursuant to federal Indian Child Protection and Family Violence Prevention Act requirements.

Knowledge, Skills and Abilities:

1. General knowledge of case management practices, including familiarity with relevant products and services.

2. Knowledge of resources in Fairbanks, Anchorage, and rural Alaska including knowledge of Medicaid, Medicare and Veterans Affairs.

3. Clinical knowledge of chronic conditions, such as congestive heart failure or dementia.

4. Strong interpersonal, written and verbal communication skills with patients, physicians and other stakeholders.

5. Demonstrate the ability to assess and respond to patient and family needs in a timely manner.

6. Requires creative thinking, prioritizing, and flexible problem solving skills.

7. Demonstrated teamwork experience.

8. Work independently in the absence of supervision.

9. Proficiency using Office computer (MS Office Suite) and clinical computer applications (Athena).

10. Knowledge of quality management and improvement processes for the evaluation and improvement of the quality of clinical services.

11. Establish and maintain effective working relationships with those contacted in the course of work, including service representatives and the general public.

12. Ability to obtain Alaska driver's license within 30 days of hire.

13. 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.