Sault Tribe
  • - Health
  • MI, USA
  • Year Round - Full Time

The Nurse Case Manager, under the supervision of the Medical Director, is responsible for providing nursing services to patients in our ambulatory care clinics.  The primary focus is on population health management, namely the aggregation of patient data across multiple health information technology resources, the analysis of that data into a actionable patient record, and the actions through which care providers can improve both clinical and financial outcomes.  The position is responsible for promoting the coordination and continuity of care, providing patient education and preventive care and health maintenance services to clinic patients.  The case manager will work to eliminate task and intervention duplication, promote adherence to plans of care, and implement the plans of care to ensure completion and follow-up through the use of RPMS iCare and other appropriate RPMS/EHR applications.                                                                                               

ESSENTIAL FUNCTIONS: (includes, but is not limited to, the following)

 

  • Creates and manages patient lists (panels) using specific      user-defined criteria with clinic providers.
  • Provides proactive identification and management of different      groups (populations) of patients who share user-defined characteristics.
  • Facilitates provider review of clinical quality of care,      prevention and treatment measures for their own patients to identify      trends in care and to increase awareness of the services that patients      need.
  • Incorporates various physician or group practice incentive      programs including Meaningful Use (MU), Medicare Access and CHIP      Reauthorization Act (MACRA) and other Third Party incentive programs      (e.g., BCBS PGIP) when developing clinical guideline tracking and      follow-up parameters to maximize financial outcomes.
  • Coordinates the care delivered to specific groups of patients and      facilitates communication between care providers and other health      disciplines.
  • Coordinates EHR Care Management Event Tracking (CMET) and/or other      applications to ensure appropriate review of results, recommendations for      follow-up, and completion of patient recall & notification.
  • Implements or assists in developing corrective action      recommendations and follow-up on accreditation surveys and quality of care      reports (e.g., GPRA, HEDIS, patient satisfaction, and others).
  • Oversees the implementation of preventive and health maintenance      reminders and completes tracking and recall on recommended clinic      interventions.
  • Assists medical director in developing Quality Improvement (QI)      plans and projects to ensure that adopted clinical guidelines are followed      and that outcomes are monitored.
  • Develops, implements, updates and maintains individualized nursing      care plans of clients.
  • Provides primary health care and generalized treatments      independently,  Intervenes to      promote, maintain, or restore health or to prevent illness.
  • Utilizes nursing and motivational      techniques to teach and instruct patients and families to manage illness,      restore health and to promote healthy lifestyles.                                                       

 

ADDITIONAL RESPONSIBILITIES: (includes, but is not limited to, the following)

 

  • Exercises sound clinical judgment based upon current professional      standards of practice.
  • Collaborates with health care providers and appropriate health      care team members within and outside the Health Division.
  • Orients other nurse case managers, providers, other clinic and      community health nurses and others on various case management programs,      initiatives and process requirements.
  • All other job related duties as assigned.

 

CONTACTS:           

Immediate peers, peers in other departments, immediate supervisor/manager, managers in other departments, customers, outside vendor/service providers and students.

 

PHYSICAL REQUIREMENTS:

 

Position type medium with lifting of 50 pounds maximum and frequent lifting/carrying up to 25 pounds. Physical factors include constant use of hearing, smell, near/midrange/far vision, depth perception, color/field of vision and typing; frequent standing, walking, sitting; occasional carrying/lifting, pushing/pulling, stooping, kneeling, reaching and manual handling, (driving?), and bending. Working conditions include frequent exposure to weather, noise and air quality and occasional exposure to extreme heat/cold, wet/humidity and vibration. Potential hazards include constant client/patient contact, computer use, equipment and medical equipment use and cellphone/videoconference equipment use; frequent infectious exposure and occasional exposure to electric shock, chemicals, insecticides/pesticides and needles and syringes. Must wear appropriate Personal Protection Equipment (PPE) for clinical situations encountered.

 

REQUIREMENTS:

 

Education: Associates Degree in Nursing required. Bachelor's Degree in Nursing preferred.

 

Experience: Minimum of 2 years of nursing experience required.  Case management, population health, and clinical quality based incentive program experience preferred.

 

Certification/License:  Michigan RN License required. Cardiopulmonary Resuscitation (CPR) Certification required. Basic Cardiac Life Support (BCLS) Certification required. Case Management Certification from American Nurses Credentialing Center (ANCC) required within 2 year of employment. Will be required to undergo and successfully pass a background check. Must maintain a good moral character standing. Must  be able to obtain GSA vehicle clearance and be able to drive to Tribal clinics when necessary. Will be required to complete and pass pre-employment drug testing.

 

 

 

 

Knowledge, Skills and Abilities: Knowledge of population health principles and practices and physician or health practice incentive structures required. Knowledge of quality improvement concepts, applications, data analysis and QI methodologies required. Must be able to establish and maintain effective communication with co-workers, supervisors, other internal/external health team members, guests and patient. Prior knowledge and experience managing large, complex projects in a team environment required. Proven analytical knowledge and ability to identify problems, developing solutions and implementing effective courses of action required. Must demonstrate a wide theory base and sound clinical skills to interact effectively with physicians, health team members, community agencies and clients/families with diverse opinions, values, and religious and cultural ideals. Must have prior knowledge of nursing theory, standards of practice and various clinical practice guidelines. Must be knowledgeable on infection control, safety regulations and health care accreditation. Must be knowledgeable of professional boundaries, ethics, delegation, and scope of practice. Must have knowledge of clinical documentation and use of electronic health care record systems. Must have strong communication skills, including the abilities to effectively communicate verbally and in writing, at all levels of the organization. Must have strong leadership skills with the ability to work successfully within a project team setting. Must be able to prepare clear, concise, and accurate and grammatically correct written reports, letters, memoranda, plans, policy and procedural drafts and other written documents and reports using Word, Excel and PowerPoint applications. Must utilize nursing process to assess, plan, implement and evaluate health needs and to develop appropriate plans of care. Must be able to handle challenges and pressure typical in an ambulatory care setting.  Must be flexible in scheduling daily workload and able to work extra hours as the project or task demands. Must be able to communicate verbally and clearly in English. Must maintain confidentiality. Native American preferred.

 

Sault Tribe
  • Apply Now

  • Sign Up For Job Alerts

  • Share This Page

.
Sault Tribe Home History & Culture Membership Services Government Enterprises Newsroom About Us