Nurse Case Management Specialist (Chronic Care)

Tohono O'odham Nation Healthcare; San Simon (AZ); On-site; USD 70,000 - 95,000; Full time

Job summary

The Tohono O'odham Nation Healthcare seeks a Nurse Specialist (Case Management) to provide outpatient case management and self‑management education for patients with chronic diseases. The role supports the primary care team across TONHC ambulatory settings, including Sells Hospital and all health centers, coordinating care and referrals to community resources.

You will educate patients and families, arrange transportation and appointments, monitor progress, and help reduce hospital readmissions

Qualifications

• Licensed RN with active license in good standing.
• Minimum one year of clinical experience in case management or equivalent.
• Knowledge of chronic disease management and patient education.
• Ability to coordinate care across multidisciplinary teams and services.

Responsibilities

• Coordinate care plans for TONHC beneficiaries and manage referrals.
• Educate patients and families about chronic disease management and services.
• Arrange transportation and schedule specialty appointments as needed.
• Monitor patient progress and maintain comprehensive documentation.
• Communicate results and recommendations to primary care teams.
• Collaborate with community partners to connect patients with resources.

Skills

Case management

Chronic disease care

Patient education

Multidisciplinary teamwork

Communication

Education

Registered Nurse License

Tools

RPMS data

Microsoft Word

MS Outlook

Job description

The Tohono O'odham Nation Healthcare seeks a Nurse Specialist (Case Management) to provide outpatient case management and self‑management education for patients with chronic diseases. The role supports the primary care team across TONHC ambulatory settings, including Sells Hospital and all health centers, coordinating care and referrals to community resources.

You will educate patients and families, arrange transportation and appointments, monitor progress, and help reduce hospital readmissions