RN Case Manager

Great Plains Tribal Leaders Health•Rapid City, SD

About The Position

The RN Case Manager supports the organization’s mission, vision, values, and strategic priorities by providing patient-centered care coordination and care management within a Medical Home model. The role provides care in accordance with evidence-based care coordination principles and assesses, plans, implements, coordinates, monitors, and evaluates care for assigned patients. The position focuses on coordinating care after emergency department visits, inpatient hospitalizations, specialty referrals, and identified care gaps. Its goals include promoting continuity of care, improving patient outcomes, reducing avoidable utilization, and supporting patient self-management. The RN Case Manager works closely with providers, community resources, and the Senior RN Case Manager so patients with complex, high-risk, or escalating needs receive appropriate interventions across the continuum of care. The role also provides direct nursing care as required by patient needs, care transitions, or staffing demands, supporting safe, high-quality, culturally responsive care and an efficient, seamless patient experience.

Requirements

Graduate of a state-approved Registered Nursing (RN) program; an Associate Degree in Nursing, diploma, or higher is acceptable.
Current Registered Nurse (RN) 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.

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

Provide coordinated, team-based, whole-person care across the lifespan within a patient-centered Medical Home.
Manage assigned patient panels using risk stratification, care-gap identification, and follow-up strategies.
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.
Coordinate care among providers, service lines, and community resources to support timely access, continuity, and appropriate service utilization.
Coordinate transitions of care and follow-up after emergency care, hospitalizations, specialty visits, or changes in level of care.
Maintain care coordination and tracking systems to ensure 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, resolve complex cases, and escalate concerns appropriately.
Provide direct nursing care as required by patient acuity, staffing needs, or care transitions, including assessments, interventions, and patient education across the lifespan.
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.
Comply with infection prevention, safety, privacy, and regulatory requirements.
Attend required meetings and training, complete competency validation and continuing education, and perform related duties consistent with licensure and role.