Nurse Specialist (Case Management)

PLEASE NOTE - This position may require temporarily relocation to other TONHC Facilities: Sells Hospital, Santa Rosa Health Center, San Simon Health Center, and San Xavier Health Center.

Position Summary:

The Nurse Specialist (Case Management) (NCM) provides outpatient case management and self‑management education to persons with chronic disease and 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, understanding the obstacles patients face to receive care, and being flexible and resourceful are critical attributes needed to navigate the ever‑changing healthcare system. Additionally, the NCM often assists in addressing and resolving social issues of the patients and families served. Occasionally, the NCM provides services 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 TONHC and serves in the ambulatory care setting. It may be situated organizationally in TONHC Sell hospital or any TONHC health centers. The NCM works under the general supervision of the Clinical Director, who provides administrative oversight. The incumbent functions with considerable independence in coordinating with care teams and performing case management duties.

Essential Duties and Responsibilities:

(Depending on the area of assignment, an incumbent may not be required to perform some of the duties listed below):

• Works alongside the primary care team to assist individuals in promptly accessing needed specialty medical care.
• Problem‑solves multiple obstacles to care for patients and families facing complex health problems in various socioeconomic contexts.
• Provides care coordination for persons with specialized and complex healthcare needs.
• Educates patients and families regarding the recommended services, their 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 obtains visits, procedures, 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, including programs within and outside the Tohono O'odham Nation.
• Monitors progress, condition, and discharge plan for TONHC beneficiaries hospitalized in and outside Tucson, Casa Grande, and Phoenix facilities.
• Provides information to primary care teams to ensure the client receives hospital discharge follow‑up in a timely manner to decrease hospital readmissions.
• Conducts chart reviews of patients whom NCM follows.
• Fields inquiries via incoming calls regarding services available at TONHC.
• Follows up and attends scheduled clinic visits with patients followed by NCM.
• Assists with scheduling specialty appointments, including entering referrals and faxing documents needed for transportation.
• Assists with scheduling transportation for medical appointments.
• Performs task‑oriented work based on patient needs.
• Communicates with patients and families in person, by phone, or by correspondence.
• Frequently communicates with specialty schedulers within the TONHC referral network and with local community partners.
• Communicates with Community Health Representatives and Home Health Nurses to contact difficult‑to‑reach patients and families and obtain useful clinical reports.
• Attends community events to share information about services available to TONHC.
• Reviews area hospital admissions via remote access for TONHC beneficiaries and communicates relevant information to the primary care team.
• Compiles a listing of beneficiaries discharged from area hospitals or transferred to area hospitals from the Sells ER or TONHC ambulatory clinics.
• Coordinates weekly conference calls among all Clinical Nurse Team Leaders, Social Work Services, and TON Home Health Nursing to improve coordinated continuity of care and reduce risk of hospital readmission.
• Participates in the TONHC care conference – a collaborative meeting with Adult Care, Senior Services, Behavioral Health, Home Health Nursing, and Community Health Representatives putting action plans in place for vulnerable individuals followed by the various programs.
• Coordinates the Monthly Collaboratively Meeting with our Community Partners, including creating an agenda and arranging a program presentation to update attendees about local services to community members and scheduling the meeting by video conference to all TONHC clinical sites.
• Participates in the Monthly Ambulatory Care Committee Meetings.
• 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.
• Uses patient and family education codes in documentation; develops a process to assist the patient with establishing a goal‑oriented plan for behavior change.
• Uses teaching strategies that include various 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 the 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 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, measurable work plan for project activities.
• Ensures that all case management and patient education activities performed are 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 the 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, multidisciplinary clinical treatment, TONHC clinical care policies, medication protocols, and patient self‑management education.
• 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 identify essential case management functions and provide needed intervention.
• Ability to assess patients' learning self‑care and behavior change needs and develop and implement individualized care plans.
• Knowledge in adult learning behavioral change and lifestyle counseling techniques, the ability and skill to enhance learning and behavior change.
• Ability to accomplish targeted goals through multidisciplinary teamwork.
• Ability to communicate effectively, verbally and in writing, with patients, community members, professional and non‑professional staff.
• Skills that integrate an understanding of the social and cultural context and needs of the people who receive care at TONHC.
• Knowledge of professional nursing principles, practices, procedures, standards of care, and concepts applied to case management.
• Ability to independently develop, implement, maintain, and evaluate a comprehensive care 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 and document findings.
• Ability to use computer programs such as Microsoft Word, MS Outlook, internet information acquisition, and accessing RPMS data.
• Ability to operate medical equipment includes blood pressure machine, Accu‑check and glucose machine, sphygmomanometer, and other related equipment.
• Ability to work extended hours and various work schedules.
• Ability to work independently and meet strict timelines.
• Ability to operate a department vehicle.

Minimum Qualifications:

• Registered Nurse License.
• One year of clinical experience as a registered nurse, case management, or an equivalent combination of training, education, and work experience that demonstrates the ability to perform the duties of this position.

Licenses, Certifications, Special Requirements:

• Must possess an unrestricted license as a Registered Nurse.
• Must possess and maintain certification in Basic Life Support (BLS)/Cardio Pulmonary Resuscitation (CPR).
• Upon recommendation for hire, a criminal background and a National FBI fingerprint check are required to determine suitability for employment, including a 39‑month driving record.
• May require possessing and maintaining a valid driver's license (no DUIs or major traffic citations within the last three years).
• Must meet the Tohono O'odham Nation tribal employer's insurance requirements 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.