Nurse Care Manager (RN)

SDUIH; Pierre (SD); On-site; USD 75,000 - 95,000; Full time

Benefits offered by this job

Holiday, PTO, Sick, and Wellness Leave

Health, Dental and Vision Insurance

Life Insurance

Short‑Term and Long‑Term Disability

401(k) with company match

Job summary

SDUIH is seeking a Registered Nurse Care Manager to provide nurse-led care coordination with in-home remote chronic disease monitoring, collaborating with the clinic team, CHR, and providers. You will address diabetes, hypertension, and hyperlipidemia, aiming to improve outcomes, intervene early, and reduce chronic disease burden.

You will work within the Nursing Team to ensure culturally appropriate, mission-aligned care, reporting to SDUIH policies and participating in team-based quality care

Qualifications

• RN license required and current with South Dakota Board of Nursing.
• Background check required; no felony violations related to ICHA.
• Provide Indian Preference documentation if claimed.
• Valid driver’s license required.
• Be a positive role model for the community.

Responsibilities

• Identify and enroll high‑risk patients into care coordination.
• Develop individualized care plans and coordinate with medical providers.
• Carry out orders and assist providers to ensure quality care.
• Conduct routine outreach via phone, in-person, or virtual visits.
• Educate patients on health promotion and self‑care procedures.
• Maintain inventory of medical supplies and equipment.
• Report accidents or incidents per SDUIH policies and HIPAA rules.
• Maintain a flexible schedule, including evenings and weekends.

Skills

Care coordination

HIPAA compliance

Communication

Independent decision making

Interagency coordination

EHR documentation

Patient relationship

Time management

Travel availability

Tools

RPMS Scheduling GUI

Electronic Health Records (EHR)

Job description

SDUIH OVERVIEW:

South Dakota Urban Indian Health, Inc. is a mission-driven nonprofit healthcare organization dedicated to delivering high-quality, patient-centered care through two full-time primary care clinics serving Native and urban communities across South Dakota. Headquartered in Pierre and operating in partnership with the Indian Health Service, SDUIH is committed to advancing the health, wellness, and quality of life of the communities it serves.

Joining SDUIH means becoming part of our Tiwahe — our family. We foster a supportive and empowering workplace culture built on equitable pay, flexibility, professional growth, and employee wellness. SDUIH employees enjoy traditional benefits, such as:

• Holiday, PTO, Sick, and Wellness Leave
• Health, Dental and Vision Insurance options
• Life Insurance – provided by SDUIH
• Short-Term and Long-Term Disability provided by SDUIH
• Participation in a 401(k) with a company match

SDUIH CLINIC NURSING PROCESS:

The SDUIH Nursing Team takes a collaborative and unique approach to caring for our patients, that focuses on the individual’s needs, preferences, and values. As the Nurse Care Manager your role will include nurse-led care coordination with in-home remote chronic disease monitoring in collaboration with the clinic-based care team, Community Health Representative (CHR), and providers. This collaboration will address the challenges associated with diabetes, hypertension and hyperlipidemia with the goal to improve health outcomes, provide early interventions, and reduce the burden of chronic disease. Decision-making authority regarding diagnosis, referral, and/or treatment for SDUIH patients is referred to the Medical Provider team. The RN must work effectively within the Nursing and Inter-Professional Team, while promoting open communication, mutual respect, and shared decision-making to achieve the highest quality patient care, while upholding the organizational Mission & Values.

POSITION SUMMARY:

Nursing staff will provide direct patient care that is safe, reliable, efficient, effective, and within their scope of practice as a Registered Nurse to ensure quality care is provided that is culturally appropriate, mission aligned and in compliance with SDUIH patient care procedures and program policies.

QUALIFICATIONS:

• Must possess current (RN) Nursing License through the South Dakota State Board of Nursing, with no history of Board Violations or issues.
• Pass a federal background check. Must not have any felony convictions that relate to the Indian Child Welfare Act.
• Provide Indian Preference documentation, if claimed.
• Must possess a valid driver’s license.
• Be a positive role model for the community and others.

KNOWLEDGE OF:

• Private, local, state and federal resources for the treatment and care of patients.
• Current documentation and coding (ICD-10 & CPT).
• Federal reporting requirements, i.e. Government Performance Reporting Act (GPRA) and UDS requirements.
• HIPAA and OSHA rules and requirements.

SKILLS & ABILITY TO:

• Enforce HIPAA requirements and maintain confidentiality.
• Assist in performing direct patient care and diagnostic treatments as needed including the execution of standing orders.
• Extensive knowledge of chronic disease management, specifically diabetes, hypertension and hyperlipidemia, its impact on the body and long-term outcomes.
• Knowledge of remote monitoring equipment and its use and capabilities along with education and proper use maintained by the patients.
• Assess for and provide support for Social Determinants of Health including but not limited food access, housing stability, transportation, literacy needs, and other drivers of health and wellbeing.
• Perform nursing assessment and document into Electronic Health Record system.
• Establish and maintain a positive effective relationship with patients, families, and staff.
• Coordinate services for patients with other agencies (i.e. AWC, WIC, SNAP, DSS, etc.)
• Document the release, transfer and receipt of medical records in accordance with HIPAA requirements and current SDUIH policy.
• Use general office equipment and computers at a proficient and accurate level.
• Prioritize, coordinate, organize and schedule appointments and services.
• Register and schedule patients through RPMS/Scheduling GUI.
• Read, process, and/or prepare reports, records, and recommendations.
• Travel on a daily/weekly basis.
• Ability to work independently with sound decision making skills.

RESPONSIBILITY & DUTIES:

• Identify and enroll high-risk patients into care coordination services.
• Develop individualized care plans.
• Carry out orders and assist medical providers to ensure quality patient care is provided.
• Conduct routine outreach through phone, in-person, or virtual visits to check in with patients, address barriers, and support adherence to care plans.
• Instruct patients concerning health promotion in relation to their treatment, by education on procedures/treatments/care and providing resources to assist them.
• Assist with maintaining an inventory of equipment and medical supplies.
• Immediately report and document all accidental or negligent incidents as they relate to patients according to SDUIH policies and procedures. Understand and comply with all State, Federal, and/or all other SDUIH organization/program required regulations, quality assurance and/or safety standards that establish minimums of care. Participating in clinic quality review care procedures and processes.
• Prepare and transmit requests for medical records in accordance with current SDUIH policy and HIPAA compliance.
• Perform other duties as assigned.
• Ability to maintain a flexible work schedule, including evenings and weekends, with Core Clinic Hours being:
  • Monday to Thursday: 08:00 am – 05:00 pm and Friday: 08:00 am – 12:00 pm

STANDARD REPORTING REQUIREMENTS:

• Completes and updates individual care plans for all patients enrolled in the program.
• Completes required reports for grant reporting.
• Completes specialized reports at the request of the Executive Director.
• Maintains appropriate files, documentation, and reports, according to the Nursing Standards of Care.

PHYSICIAL DEMANDS:

• Involves direct and frequent contact with potentially unstable clients.
• Involves direct contact with clients who may have infectious diseases.

LICENSES AND CERTIFICATIONS:

• Licensed by the South Dakota State Board of Nursing as a Registered Nurse (RN).
• Must be CPR certified or be willing to obtain CPR certification within 30 Days of employment.
• Certified in basic First Aid.

SDUIH has the right to amend this job description as operational needs dictate. SDUIH is an at-will employer.

INDIAN PREFERENCE In accordance with IHS policy and Federal guidelines, preference will be given to qualified Indian applicants in accordance to Section 703 (i) of the Title VII of the Civil Rights Act of 1964. SDUIH is an Equal Opportunity Employer. Must be able to provide Indian Preference documentation if claimed.