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Hours Full-time
Location Sells, AZ
Sells, Arizona

About this job

Nurse Specialist (Case Management)  Position Summary: The Nurse Specialist (case Management), also known as Nurse case Manager (NCM), provides outpatient case management and self-management education to persons with chronic disease and/or special healthcare needs. Other duties include assisting with the planning and implementation of community based prevention and education activities. The NCM serves a vital role within the primary care team. Knowledge of the community served, understanding the obstacles to care that our patients face, and the ability to be flexible and resourceful are key attributes needed to navigate the ever-changing healthcare system. Additionally, the NCM often assists in addressing/resolving social issues of the patients/families served. Many times NCM services are provided for an entire family as a relationship of trust develops, and people become more likely to return for additional assistance when needed. Scope of Work: This position is located within Tohono O'odham Nation Health Care (TONHC), and serves in the ambulatory care setting. It may be organizationally located in Tohono O'odham Nation Sells Hospital or in any TONHC health center. The Nurse case Manager (NCM) works under the general supervision of the Clinical Director, who provides administrative supervision. Incumbent functions with considerable independence in coordinating with care teams and performing case management duties. Essential Duties and Responsibilities: Works alongside the primary care team to assist individuals in accessing needed specialty medical care in a timely manner. Problem solving related to multiple obstacles to care patients and families face when dealing with complex health problems in various socioeconomic contexts. Provides care coordination for persons with specialized and complex healthcare needs. Educates patients and families in regard to the recommended service, its expected benefits, risks, and alternatives. Facilitates scheduling of the specialty appointments and ensures transportation to and from is arranged. Follows up to verify appointment attendance and obtain visit, procedure, and test reports for the patient's medical records. Ensures the primary care team is aware of test results, treatments, and consultants' recommendations. Connects the patient/family with appropriate resources by referral to community services for which they may be eligible. This includes programs both in and outside of the Tohono O'odham Nation. Monitors progress, condition, and discharge planning needs of TONHC beneficiaries who are hospitalized in outside facilities in Tucson, casa Grande and Phoenix. Provides information to primary care teams to ensure client receives hospital discharge follow up in a timely manner in an effort to decrease hospital readmissions. Conducts chart reviews of patients who are followed by NCM. Fields inquiries via incoming calls regarding services available at TONHC. Follows up with and/or attends scheduled clinic visits with patients followed by NCM. Assists with scheduling of specialty appointments, including entering referrals and faxing documents needed for scheduling. Schedules transportation to and from visits. Performs task-oriented work based on patient needs. Communicates with patients/families in person, and by phone and letters. Frequently communicates with specialty schedulers in the TONHC referral network, and with local community partners. Communicates with CHR's (Community Health Representatives) and Home Health Nurses in order to contact difficult-to-reach patients/families and obtain clinically useful reports. Attends community events to share information about services available at TONHC. Reviews area hospital admissions via remote access for TONHC beneficiaries and communicates relevant information the primary care team. Compiles listing of beneficiaries who have been discharged from area hospitals. Compiles listing of beneficiaries who have been transferred to area hospitals from the Sells ER or TONHC ambulatory clinics. Coordinates weekly conference call among all Clinical Nurse Team Leaders, Social Work Services & TON Home Health Nursing to improve coordinated continuity of care and reduce risk of hospital readmission. Participates in TONHD care Conference - a collaborative meeting with Adult care, Senior Services, Behavioral Health, Home Health Nursing & Community Health Representatives where action plans are put in place for vulnerable individuals followed by the various programs. Coordinates the Monthly Collaborative Meeting with our Community Partners. This includes creating an agenda, and arranging for a program presentation to update attendees about services available locally to community members. This meeting is available by tele-video conference to all TONHC clinical sites. Participates in the Monthly Ambulatory care Committee Meeting. Conducts patient assessments and provides appropriate case management and referral for persons with chronic disease. Uses reliable, evidence-based, culturally relevant education material or curricula for providing comprehensive patient self-management education. Documents educational assessment, topics covered and evaluation of the patient's understanding in the medical record. Utilizes Patient & Family Education Codes in documentation; develops a process to assist the patient with establishing a goal orientated plan for behavior change. Uses teaching strategies that include a variety of approaches and methods that incorporate theories and concepts related to adult learning, readiness for change, empowerment and motivational interviewing. Collaborates with the multidisciplinary team to develop and implement a patient care plan that meets relevant standards of care; evaluates educational process and clinical outcomes and makes appropriate referrals. Uses case management techniques to monitor education and clinical interventions for individual clients; routinely monitors group data for performance improvement activities. Procures, organizes, evaluates, updates, and develops patient education materials for use by health care professionals, patients and family members. Maintains continuing education in chronic disease treatment, case management, patient education, teaching strategies, behavior change and other topics related to the scope of work. Assists in the development of protocols and procedures according to relevant guidelines. Assists in the development of a realistic, measureable work plan for project activities. Ensures that all case management and patient education activities are performed with the utmost attention to patient confidentiality and HIPAA requirements. Participates actively in case management training. Maintains collaborative relationships with members and tribal and community partners. Performs other job related duties as assigned and contributes to a team effort. Knowledge, Skills, and Abilities:  Knowledge of Tohono O'odham traditions, language, history, geography, and culture. Knowledge of applicable federal, state, tribal laws, regulations and requirements. Knowledge of health related issues, medical terminology, and health and child care education. Knowledge of case management skills such as tracking, recall, identification of clinical needs, and communication. Strong working knowledge of chronic disease (including but not limited to: diabetes, cardiovascular disease, hypertension, dyslipidemia, depression and rheumatoid arthritis); physiology and pathophysiology, clinical multidisciplinary treatment, TONHC clinical care policies, medication protocols and patient self-management education. Ability to identify essential case management functions and provide needed interventions. Ability to assess patients' learning, self-care and behavior change needs; develop/implement individualized plans of care. Knowledge in the areas of adult learning, behavior change and lifestyle counseling techniques; the ability/skill to enhance learning and behavior change. Ability to accomplish targeted goals through multidisciplinary teamwork. Ability to communicate effectively, both verbally and in writing, with patients, community members, professional and non-professional staff. Skills that integrate an understanding of the social and cultural context/needs of people who receive care at TON Sells Hospital. Knowledge of professional nursing principles, practices, procedures, standards of care and concepts as it applies to case management. Must maintain current certification in BLS/CPR as a mandatory requirement. Ability to independently develop, implement, maintain and evaluate a comprehensive case management program and patient and provider education. Ability to independently adjust teaching methods for unique patients and families, paraprofessionals, professionals and special situations. Ability to independently perform a clinical assessment, implement needed care and report/document findings. Knowledge of clinic policy and procedures, including but not limited to, quality control measures for blood glucose monitoring equipment, universal precautions, patient education standards and confidentiality issues. Ability to use computer program such as Microsoft Word, Microsoft Outlook, Internet information acquisition and accessing RPMS data. Ability to operate medical equipment to include: blood pressure machine, accu-check and glucose machines, sphygmomanometer, and other related equipment. Ability to work extended hours and various work schedules. Ability to work independently and meet strict time lines. Ability to operate company vehicles. Minimum Qualifications:  Unrestricted License as a Registered Nurse. At least two years clinical experience as a registered nurse Licenses, Certifications, Special Requirements:  Must obtain certification in Basic Life Support within one year of hire. Unrestricted License as a Registered Nurse. Upon recommendation for hire a criminal background and fingerprint check is required to determine suitability for hire. Must possess and maintain a valid United States driver's license. If it will be necessary for the incumbent to operate Tohono O'odhani Nation vehicles, the incumbent must meet the Tohono O'odham Nation tribal employer's insurance reguirements to receive a driver's permit to operate program vehicles.Based on the department's needs, incumbents may be required to demonstrate fluency in both the Tohono O'odham Language and English as a condition of employment. Physical Demands:  While performing the duties of this job, the employee is regularly required to stand; walk; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The ability to talk and hear is essential. Visual abilities needed include close vision, distance vision, depth perception and the ability to focus. The employee must occasionally lift and/or move up to 30 pounds. Work is predominantly in a hospital setting, in the outpatient clinical setting as well as classroom and office settings. Community interventions are indicated. Exposure to contagious disease and blood and body fluids does exist. Standard precautions are to be used when necessary. Exposure to patients with a variety of emotional and violent behaviors does exist. This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive. Arizona Daily Star. Keywords: Registered Nurse (RN), Location: Sells, AZ - 85634