Case Management Nurse: Complex Care & Transitions

Indian Health Service; Fort Thompson (SD); On-site; USD 75,000 - 110,000; Full time

Job summary

The Indian Health Service at Fort Thompson Health Center in Fort Thompson, SD, seeks an experienced registered nurse to independently plan and execute case management for patients with complex acute and chronic conditions, serving as a clinical resource for discharge planning.

You will coordinate care across providers, design transition plans, educate patients and families, and deliver direct nursing care for chronic conditions within a collaborative team.

Qualifications

• RN must hold an active license in good standing
• Education and experience supporting complex care planning and transitions
• Evening, after-hours, or weekend work may be required to support patient care

Responsibilities

• Coordinate care across providers, disciplines, and care settings to ensure continuity and prevent fragmentation of services.
• Provide transition of care for patients with complex needs, designing individualized transition plans addressing nonroutine discharge barriers.
• Educate patients and families about disease processes, medications, treatment plans, self-management, and post-discharge care using established materials.
• Provide direct professional nursing care to patients with chronic and recurring health conditions.

Skills

Case management

Care coordination

Patient education

Discharge planning

Education

Nursing degree from accredited program

BSN preferred

Job description

The Indian Health Service at Fort Thompson Health Center in Fort Thompson, SD, seeks an experienced registered nurse to independently plan and execute case management for patients with complex acute and chronic conditions, serving as a clinical resource for discharge planning.

You will coordinate care across providers, design transition plans, educate patients and families, and deliver direct nursing care for chronic conditions within a collaborative team.