Incumbent serves as an Outpatient/Inpatient RN Case Manager for TCRHCC and Sacred Peaks Healthcare Center (SPHC) as the supportive contact for specified groups of identified high risk patients; will specifically focus on specialty clinics that need specific Case Management attention. The Case Manager meets essential health, education and social needs for patients while ensuring quality, cost effective healthcare. The case manager facilitates care transitions from admission through discharge ensuring continuity of care, alignment of services, and post hospital referrals to continuing care agencies. Also serves as a resource for nursing, physicians and ancillary departments on transitional and regulatory issues The Case Manager will experience working with culturally diverse patient populations having multiple barriers to self-sufficiency such as: illiteracy, welfare dependency, domestic violence, substance abuse, and mental health issues. Will be responsible for assessment, service planning, resource acquisition, monitoring progress and initiating the responding to emerging client needs.
- Provides comprehensive and client centered service planning and coordination for a specified group of high risk patients.
- Manages care of prioritized TCRHCC/SPHC outpatient/inpatient based upon consultation from providers within the TCRHCC/SPHC healthcare delivery system; provides a consistent and on-going consultation with service providers.
- Works collaboratively with providers and other disciplines to develop and maintain high risk patient database to ensure the continuity of care is established and maintained for the TCRHCC/SPHC outpatient/inpatient population.
- Works proactively and collaboratively with Utilization Review (UR), Public Health Nursing (PHN), Patient Benefit Coordinators (PBC), and Purchased Referred Care (PRC) at TCRHCC/SPHC.
- Facilitates communication and coordination between members of the health care team, involving the client in the decision-making process in order to minimize fragmentation in the services (CMSA, 2010).
- Independently develops and maintains resource database to ensure timely and accurate information for patient referrals and minimize fragmentation in patient care services.
- Develops with the patient/family and multidisciplinary team (including service area and/or other non-TCRHCC/SPHC providers as appropriate) a care and service delivery plan based upon the needs identified and available provider and financial resources of the patient and provides consistent and on-going case consultation with all direct service providers.
- Provides service monitors and follow up to ensure continuity of care, and updates of the client service plan and provides follow up if needed. Striving to promote client self-advocacy and self-determination (CMSA, 2010).
- Prepares patient and family for termination (discharge) from case management when services are no longer required. Arranges for any ongoing support/direct care services that the patient will need post-discharge in coordination with discharge planners and other entities such as PHN, Community Health Representatives or Tribal Social Services. Will provide follow-up phone call for high risk patients.
- Develops reports, performance improvement projects, establishes policy and procedures and program objectives.
- Will provide Case Management coverage for the Adult Care Unit, Pediatric Unit, Intensive Care Unit, Obstetrics Unit, Emergency Room and Outpatient Departments.
- Will be familiar with Advance Directives, and be a resource person for patients and families; facilitate informed choice, consent, and decision-making.
- Promote use of evidence-based care, as available, in conjunction with the MCG Care Guidelines.
- Pursue professional excellence and maintain competence in practice.
- Serves as the outpatient/inpatient coordinator, such as:
- The primary contact for outpatient/inpatient in obtaining beds for admissions both within and outside of TCRHCC/SPHC.
- Collaborates with provider and nursing personnel to ensure admissions are conducted seamlessly and without delay of patient care.
- Collaborates with provider, nursing personnel and patient benefits coordinators that all admission documentation is complete and all referrals for third party resources are complete prior to the departure of patients.
- Required to take call on scheduled weekends as deemed necessary.
- Responsible for electronic health records data entry pertinent to patient service role.
- Performs Other Duties as Assigned.
The individual shall perform a variety of responsible nursing care procedures requiring professional knowledge and consideration of specific patient conditions and treatments and an ability to work independently in completing assignments. Performs within established objectives/parameters and independently work out and revise methods, processes and procedures with professional and other staff. Identifies and seeks innovative approach to resolution of problems. Seeks assistance and identify when limitations have been reached.
MENTAL AND PHYSICAL EFFORT
The physical and mental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
Work requires walking, periods of standing, and sitting. Work also requires extensive periods of time working at a personal computer. Must be able to lift up to 25 lbs (i.e. medical charts); must be able to distinguish numbers, letters, and colors.
Contacts often require tact and sensitivity as those related to stressful situations such as death, dying and catastrophic illnesses. Must be able to prioritize, use good judgment, and coordinate a variety of issues while being frequently interrupted.
The RN Case Manager directly affects the proper function and quality of healthcare provided within TCRHCC/SPHC. Case Managers emerge as an important intervention that fosters the careful shepherding of health care dollars while maintaining a primary and consistent focus on quality of care and client self-determination (2010, CMSA).
TCRHCC is located within the Navajo Nation and, in accordance with Navajo Nation law, has implemented a Navajo/Indian Preference in Employment Policy. Pursuant to this Policy, applicants who are enrolled members of the Navajo Nation and who meet the necessary qualifications for this position will be given preference in hiring and employment for this position and applicants who are enrolled members of any other tribe who meet the necessary qualifications will be given secondary preference.
In performance of their respective tasks and duties, all employees at TCRHCC are expected to conform to the following:
- 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.
All employees must uphold all principles of confidentiality and patient care to the fullest extent.