RN Case Manager

Great Plains Tribal Leaders Health•Rapid City, SD

13d

About The Position

The RN Case Manager provides patient-centered care coordination and care management within a Medical Home model, supporting the organization’s mission, vision, values, and strategic priorities. The role assesses, plans, implements, coordinates, monitors, and evaluates care for assigned patients using evidence-based care coordination principles. It focuses on follow-up after emergency department visits, inpatient hospitalizations, specialty referrals, and identified care gaps to promote continuity, improve outcomes, reduce avoidable utilization, and support patient self-management. The RN Case Manager works closely with providers, community resources, and the Senior RN Case Manager so that patients with complex, high-risk, or escalating needs receive appropriate support across the continuum of care. The position also provides direct nursing care as required by patient needs, care transitions, or staffing demands, with an emphasis on safe, high-quality, culturally responsive care and efficient use of healthcare resources. Care is provided across the lifespan, from infants through older adults.

Requirements

Graduate of a state-approved Registered Nursing program; an Associate Degree in Nursing, diploma, or higher is accepted.
Current Registered Nurse license in good standing.
Three years of RN nursing experience, or one year of RN nursing experience and four years of Licensed Practical Nursing experience.
Current Basic Life Support (BLS) certification.
Submit a resume that includes complete work history and month and year for each job.
Submit Nursys licensure verification demonstrating that licensing requirements are met.
Agree to comply with job-related employee health screening and immunization requirements before the first day of employment, including MMR, varicella, Hepatitis B, influenza, Tdap, and COVID-19 vaccination.
Employment is contingent on the outcome of required criminal background checks.

Nice To Haves

Experience in a patient-centered Medical Home, care management model, or interdisciplinary team-based care.
Familiarity with referral management and care transition workflows.

Responsibilities

Manage assigned patient panels using risk stratification, care gaps, and follow-up needs.
Use population health tools, registries, and reports to monitor preventive care, chronic disease indicators, utilization trends, and outcomes.
Conduct comprehensive assessments of medical, behavioral, psychosocial, and functional needs that affect outcomes and care coordination.
Develop, implement, and evaluate individualized care plans for assigned patients.
Coordinate care across providers, service lines, and community resources to support timely access, continuity, and appropriate service use.
Coordinate transitions of care and follow-up after emergency care, hospitalizations, specialty visits, and changes in level of care.
Maintain care coordination and tracking systems to follow through on referrals, diagnostics, testing, and treatment plans.
Educate patients and families about condition management, prevention, healthcare-system navigation, and self-management.
Collaborate with providers and interdisciplinary team members to address barriers to care, adherence challenges, and social drivers of health.
Use clinical judgment and case management principles to prioritize needs, solve complex cases, and escalate concerns appropriately.
Provide direct nursing care, including assessments, interventions, and patient education, as required by patient acuity, staffing needs, or care transitions.
Participate in multidisciplinary care conferences for patients with complex, high-risk, or population-based needs.
Document care coordination, population health activities, patient education, and outcomes accurately and promptly in the electronic health record.
Participate in quality improvement, utilization management, population health, and performance improvement initiatives related to care coordination.
Serve as a clinical resource to team members on care management workflows, panel management strategies, and best practices.
Maintain compliance with infection prevention, safety, privacy, and regulatory requirements.
Participate in required meetings, training, competency validation, and continuing education, and perform related duties consistent with licensure and role.