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Nurse Case Manager - Echo Cliffs

Tuba City Regional Health Care Corporation•Coppermine, Arizona

About The Position

The Nurse Case Manager serves TCRHCC and Echo Cliffs Health Center as an outpatient/inpatient case manager and supportive contact for identified groups of high-risk patients, with particular attention to specialty clinics requiring case management. The role addresses patients’ essential health and social needs while supporting quality, cost-effective care. It facilitates transitions from admission through discharge, promotes continuity and alignment of services, and arranges post-hospital referrals. The case manager also advises nursing, physicians, and ancillary departments on transitional and regulatory matters. The position involves working with culturally diverse patients who may face barriers to self-sufficiency, including illiteracy, welfare dependency, domestic violence, substance abuse, and mental health issues. Responsibilities include assessing needs, planning services, acquiring resources, monitoring progress, and responding to emerging needs. The case manager collaborates with an interdisciplinary team to review care plans, monitor progress, and recommend measures that support safe and efficient hospitalizations. Duties also include evaluating emergency department patients for medical necessity and care coordination, assessing potential admissions and appropriate admission status with clinicians, and proposing outpatient discharge plans with physician approval. The role coordinates care for patients with abuse, chronic pain, and frequent utilization issues, and serves patients from newborn through geriatric ages. The role also helps individuals with mental health issues access and navigate resources that support their well-being.

Requirements

  • Associate’s or Bachelor’s Degree in Nursing.
  • Valid, current, full, and unrestricted professional nursing license to practice in any U.S. state, the Commonwealth of Puerto Rico, or a U.S. territory.
  • Maintain current Basic Life Support (BLS) certification from the American Heart Association throughout employment.
  • Three years of clinical nursing experience, including one year in an outpatient/inpatient setting.
  • Demonstrated knowledge of case management, contract health, and utilization review processes.
  • Satisfactory performance in prior and current employment, supported by positive references addressing working relationships, ethical standards, reliability, communication, and a proactive team approach to problem resolution.
  • Successful completion of job interviews, background and reference checks, fingerprint clearance, physical examinations, and other required screenings.
  • Submit required employment documents and information without false, misleading, or incomplete information.
  • Ability to maintain a long and flexible schedule and meet the physical and mental demands of the role.
  • Ability to lift, push, and pull up to 50 pounds frequently.
  • Ability to perform duties requiring prolonged sitting, frequent walking, bending, kneeling, crouching, twisting, balancing, reaching, hand manipulation, and keyboard use.
  • Ability to communicate and comprehend in person and by telephone, and meet the stated vision and hearing requirements.
  • Ability to use independent judgment and analytical skills, handle multiple priorities and stressful situations, adapt to shift work, and work in structured and unstructured environments.

Responsibilities

  • Provide comprehensive, client-centered service planning and coordination for a specified group of high-risk patients.
  • Manage prioritized TCRHCC/SPHC outpatient and inpatient cases based on provider consultation, and maintain ongoing consultation with service providers.
  • Collaborate with providers and other disciplines to develop and maintain a high-risk patient database and support continuity of care.
  • Work proactively with Utilization Review, Public Health Nursing, Patient Benefit Coordinators, and Purchased/Referred Care.
  • Facilitate communication and coordination among healthcare team members and involve clients in decision-making.
  • Develop and maintain resource databases to support timely, accurate referrals and coordinated patient care.
  • Develop care and service delivery plans with patients, families, and multidisciplinary teams based on identified needs and available provider and financial resources.
  • Monitor services and follow up to maintain continuity of care, update client service plans, and promote client self-advocacy and self-determination.
  • Prepare patients and families for discharge from case management and coordinate ongoing support or direct care services with discharge planners and other entities.
  • Develop reports and performance improvement projects, and establish policies, procedures, and program objectives.
  • Provide case management coverage for the Adult Care Unit, Pediatric Unit, Intensive Care Unit, Obstetrics Unit, Emergency Room, and Outpatient Departments.
  • Serve as a resource for patients and families on Advance Directives and facilitate informed choice, consent, and decision-making.
  • Promote evidence-based care, as available, in conjunction with MCG Care Guidelines.
  • Pursue professional excellence and maintain competence in practice.
  • Coordinate inpatient and outpatient admissions, including obtaining beds within or outside TCRHCC/SPHC.
  • Collaborate with providers and nursing personnel to ensure admissions occur seamlessly and without delay in patient care.
  • Work with providers, nursing personnel, and patient benefits coordinators to ensure admission documentation and third-party resource referrals are complete before patients depart.
  • Take call on scheduled weekends as deemed necessary.
  • Wear appropriate PPE while on duty, complete safe donning and doffing, and discard used PPE appropriately.
  • Complete task training for routine cleaning and decontamination of surfaces contaminated by communicable disease.
  • Perform other duties as assigned.

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