Case Manager

This position assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet a patient's needs using communications and available resources to promote quality, cost-effective outcomes. This position promotes the efficient and effective use of a variety of health care resources by focusing on the whole patient to provide a seamless continuum of care and care management for Oyate Health Center (OHC) patients. 

Essential Functions: 

• Understands key concepts including same-day access, continuity of care, empanelment, and integrated care. 
• Works effectively in a rapidly changing and innovative health care system. 
• Identify cases with potential for high-risk complications; act as an advocate for an individual's health care needs; Understand methods for assessing an individual's present level of physical/mental impairment; Assist individuals with the development of short-and long-term health goals; Understand the psychological characteristics of wellness.

• Manage OHC high-risk patient registry; Oversee systems for identifying high risk patients through electronic health records and referrals; Ensure validity of registry and collaborate with Information Technology on registry functionality. 
• Maintain a tracking system for patient care coordination and care management across the continuum, including transitional care management, tracking referred patients for admission to other healthcare facilities; performs chart reviews to determine timeliness of requested service to facilitate  the discharge of patients currently admitted to outside facilities. 
• Monitor CHEF program for CHS department and other programs, including case reviews and assures documentation is prepared and submitted timely for reimbursement. 
•  Conduct a comprehensive assessment of patients’ physical, mental, and psychosocial needs; Collect in-depth information about a person's situation and function to identify needs to develop a comprehensive Case Management plan that will address those needs. 
• Develop care plans to prevent disease exacerbation, improve outcomes, increase patient engagement in self-care, decrease risk status, minimize hospital and emergency room utilization, and are obtainable and concise with the patient needs and goals. 
• Responds to insurance providers and third-party agencies to ensure maximum reimbursement to minimize cost on clinical issues.
• Utilize behavioral strategies to help patients adopt healthy behaviors and improve self-care in chronic disease management; Promote self-management goals. 
• Assist patients in navigating the health care system; Coordinate Specialty care, execute specific case management activities and/or interventions that will lead to accomplishing the goals set forth in the case management plan. 
• Partner with external case management programs to coordinate care. 
• Provide ongoing evaluation and documentation of patient progress/risk status and communicate with care teams.
• Gather sufficient information from all relevant sources about the case management plan and its activities and/or services to enable the case manager to determine the effectiveness of the plan. 
• Record accurate, timely and appropriate information in the patient’s electronic health record; Document observations, nursing interventions, therapeutic measures administered and status of coordinated activities between nursing and other professional disciplines. 
• Initiates a patient education plan according to the individualized needs of the patient, as prescribed by medical provider and/or OHC policy, including patient and family instruction
• Assists with referrals and/or follow-up care based on with referrals and/or follow-up care based on recommendations by the outside facility medical providers patients have been referred to or as ordered during discharge from an inpatient facility.
• Utilizes skills in prioritizing needs, problem-solving, and decision-making in a clinical setting.
• Efficiently and effectively manages multiple responsibilities. 
• Responds to life-saving situations based upon nursing standards, policies, code procedures, and established protocol.
• Participates in Quality Assurance activities such as GPRA, PI, IPC, audits/peer review, discharge planning, and infection control.
• Must comply with federal laws and regulations as required by the Privacy Act of 1974 and the Health Insurance Portability and Accountability Act (HIPPA).
• Coordinates and leads multidisciplinary patient care conferences for high-risk or complex patients as needed. 
• Functions as the liaison between referral providers and Oyate Health Center Providers in regard to declined referrals. 
• Participates in department and system wide committees. 
• Provide ongoing evaluations and documentation of patient progress/risk status and communication with the care team. 
• Performs job and other related duties as assigned by the supervisor with minimal supervision. 

Required Qualifications

• Bachelor’s degree, or associate’s degree and three (3) years’ experience.
  

• Licensed as a Registered Nurse 

• Documented case management and/or administrative experience preferred.  

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The GPTLHB is a tribal organization that follows tribal preference laws. Our policy is to give preference to qualified Indian/Tribal candidates over qualified non-native candidates in hiring decisions if all other qualifications are equal. Employment is contingent upon the outcome of all required criminal background checks.