Nurse Case Manager
1 week ago
Job Title: Nurse Case Manager
FLSA Status: Exempt
Location: Indian Health Center; Santa Fe, NM
SUMMARY
The Nurse Case Manager will provide essential case management services at the Santa Fe Indian Health Center in Santa Fe, New Mexico, as part of the Indian Health Service (IHS) mission to deliver high-quality healthcare to Native American communities. This role focuses on supporting the Purchase Referred Care (PRC) program, which facilitates access to healthcare services not available within IHS facilities. Responsibilities include managing patient care coordination, processing referrals, overseeing durable medical equipment orders, and tracking care processes, with a focus on un-resourced patients. The Nurse Case Manager ensures seamless communication with clinical teams, external vendors, and healthcare partners, contributing to timely and effective patient outcomes while upholding IHS and PRC program standards.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES
- Assist with care coordination for ordering complex durable medical equipment and manage care or primarily un-resourced patients, including some resourced referrals.
- Clarify provider referrals and orders for PRC staff and shareholders (non-IHS vendors/providers).
- Facilitate communication with clinical staff and care teams to ensure referrals are appropriate and timely.
- Track referrals entered by providers to ensure follow-through.
- Collaborate with outside agency case managers and social workers for hospitalized patients with complex medical, geriatric, surgical, pediatric, obstetric, gynecologic, and trauma needs.
- Work with vendors and partners referred by IHS to ensure referral processes are completed efficiently.
- Support case management consult requests for all ambulatory clinics.
- Provide resources and input during weekly PRC Committee meetings for referral determinations.
- Participate in care team meetings and medical home strategic planning groups to provide updates and process improvement recommendations.
- Review charts and care plans; communicate with patients, families, and service providers to confirm services meet planned objectives and needs.
- Maintain electronic patient records (EHR, RPMS) for assessments, service plans, and evaluations of care.
- Assist in consultations with healthcare providers to assess care levels and PRC resource utilization.
- Determine patient eligibility for care by reviewing health records, service delivery areas, tribal membership, and residence.
- Screen patients for alternate resources, including Medicare, Medicaid, private insurance, and other third-party programs.
- Educate patients on their care plans, healthcare options, and assist in decision-making.
- Schedule medical appointments and coordinate necessary therapies and services.
- Revise care plans based on patient progress and provider input.
- Review and collect patient medical information from paper and electronic health records to complete referrals and payment decisions.
- Work with medical staff to ensure appropriate documentation is recorded for referrals to external providers.
- Conduct follow-ups to verify referrals and ensure adequate documentation is in place for patient care.
- Maintain and organize program file systems.
- Respond promptly to messages (fax, mail, or other communication methods).
- Direct telephone calls to the appropriate parties, maintaining professional communication standards.
- Fax referrals to facilities upon request.
- Advocate for patients regarding benefit determinations or bills in collection.
- Assist with identifying CHEF cases and submitting them for reimbursement from the Catastrophic Health Emergency Fund (CHEF).
- Conduct research for referrals and purchase orders.
- Contribute to achieving PRC's goals for FY2025 by participating in collective approaches.
- Collaborate with management to optimize business practices for prompt payments.
- Adhere to the Indian Health Service Manual, Chapter 3, and meet PRC requirements for prompt payments.
SKILLS AND QUALIFICATIONS
- Proficiency in IHS systems (RCIS, RPMS, EHR, iCARE) is preferred
- Proficient with general office applications (Outlook, Word, Excel, PowerPoint, iStar, ITAS).
- Knowledge of ICD, CPT, HCPCS codes, ADA codes, length of stay criteria, DRGs, Medicare, and Medicaid program benefits.
- Expertise in managed care concepts, including utilization review, clinical pathways, and discharge planning.
- Strong organizational skills to maintain program file systems and ensure timely responses to communications.
- Ability to use small office equipment, including fax, scanners, and copiers.
- Exceptional interpersonal and communication skills for patient education and professional collaboration.
- Familiarity with privacy regulations, including HIPAA and the Privacy Act of 1974.
- Bachelor's degree in Nursing from an accredited institution.
- A minimum of 36 months of nursing experience, including at least 12 months in case management.
This position does not have supervisory responsibilities.
WORK ENVIRONMENT
Work performed in a healthcare clinic setting with a standard 8-hour shift. May require rotation into other duty sections based on facility needs. Adherence to infection control and safety policies is mandatory.
Our Values:
Native American Owned & Proud | Accountable | Team Focused | Innovative | Visionary | Excellence
PHYSICAL DEMANDS
Ability to perform duties in a fast-paced clinical environment. Frequent standing, walking, and using office equipment, including computers and fax machines.
POSITION TYPE/EXPECTED HOURS OF WORK
Full-time position with an 8:00 AM - 4:30 PM schedule, including a 30-minute non-paid lunch. No on-call duties; shifts determined bi-weekly by the COR.
TRAVEL REQUIREMENTS
Regular commute to primary work location is not considered travel. Minimal travel required, limited to conferences or training related to patient care coordination.
CLEARANCE/LICENSE REQUIREMENTS
- Valid and unrestricted nursing license in the U.S., including its territories.
- Current Basic Life Support (BLS) certification required; Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) preferred.
- Must pass a Level I or II background investigation under Public Law 101-630.
- Compliance with IHS fingerprinting and character background checks.
- Completion of mandatory IHS training, including Security Awareness, Trauma-Informed Care, and yearly compliance training (No Fear Act, EEO process).
- Documentation of immunizations and TB testing in accordance with IHS standards.
AAP/EEO Statement
Ho-Chunk, Inc. is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. However, preference may be extended to persons of Indian descent in accordance with applicable laws.
Note: This position is being posted in anticipation of award of a federal contract. Employment is contingent upon Flatwater Group being awarded the contract and meeting all requirements set forth by the contracting agency. Candidates are encouraged to apply and may be contacted for further evaluation as part of the proposal process.
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