Nurse Case Manager

Tohono O'odham Nation; San Simon (AZ); On-site; USD 70,000 - 90,000; Full time

Job summary

Tohono O'odham Nation Health Care is seeking an RN with utilization review experience to assess referrals, coordinate discharge planning, and identify patient resources. The role requires collaboration with physicians and hospital staff across TONHC facilities.

Candidates should have an Associate's Degree in Nursing, an active US RN license, and at least two years of clinical nursing experience. CPR/AED certification is required; background checks may be conducted.

Qualifications

• Associate's Degree in Nursing is required.
• Current US RN license with no restrictions.
• Two years of nursing experience in a clinical setting.
• Bachelor's degree in Nursing preferred.
• CPR and AED certification required.
• Background checks and driving record review may be required.

Responsibilities

• Review referrals for specialty/hospital services under Purchased Referred Care criteria.
• Identify alternate resources for patients (Medicare/Medicaid/private insurance).
• Approve or deny services and document rationale for providers and patients.
• Review medical records to support admissions and continued stays per Interqual criteria.
• Refer patients to AHCCCS, ALTC, DDD, CRS and coordinate COB/TPL when applicable.
• Act as liaison between physicians and hospital staff; represent TONHC externally.
• Coordinate discharge plans and weekly discharge planning meetings.
• Develop and distribute reports to track utilization trends.
• Track high-cost cases and CHEF requests; prepare reports for committees.
• Perform special projects and other duties as assigned.

Skills

HIPAA compliance

Utilization review

Discharge planning

Team collaboration

Policy development

Communication skills

Education

Associate's Degree in Nursing

Bachelor's degree preferred

Job description

PLEASE NOTE - This position may require temporarily relocation to other TONHC Facilities: Sells Hospital, Santa Rosa Health Center, San Simon Health Center, and San Xavier Health Center.

Position Summary:

The incumbent provides comprehensive nursing care and patient services in a clinic or ambulatory care setting and assists physicians and patients.

Scope of Work:

This position is within the Tohono O'odham Nation Health Care, including Sells Hospital, San Xavier Health Center, Santa Rosa Health Center, and San Simon Health Center, in the Division of Purchased Referred Care as assigned. This position involves providing case management to patients. The employee is assigned to the Purchased Referred Care Division and works under the general supervision of the Director of Purchased Referred Care.

Essential Duties and Responsibilities:

• Provides a review of referrals for specialty and hospital-based services and determines whether requests are appropriate under Purchased Referred Care criteria.
• Identify alternate resources available to patients, i.e., Medicare, Medicaid, private insurance.
• Provide an approval or denial to providers and patients for requested services.
• Provides a review of medical records documentation to support accomplished through admission certification and continued stay certification according to Interqual intensity of service and severity of illness criteria.
• When appropriate, identify and refer patients to other agencies/programs such AHCCCS, ALTC, DDD, CRS, and identify and refer members for Coordination of Benefits (COB) and Third Party Liability (TPL).
• Represent TONHC as a resource person for and liaison between physicians and hospital/skilled nursing facility staff.
• Coordinate discharge for all hospitalized patients by facilitating discharge plans with a hospital or skilled nursing facility staff. Attends and facilitates weekly discharge planning with TONHC case managers and other departments as needed.
• Exercises independent judgment in developing and distributing various reports required to track utilization trends of patients and providers.
• Responsible for tracking of high-cost cases and submitting Catastrophic Health Emergency Fund (CHEF) requests. Reports provided to appropriate personnel and committees.
• Performs special projects and other duties as assigned.

Knowledge, Skills, and Abilities:

• Knowledge of the Tohono O'odham culture, customs, and traditions.
• Knowledge of HIPAA-related rules and regulations.
• Knowledge of a full range of established nursing concepts, principles, and practices to perform an inpatient utilization review.
• Knowledge of current utilization management principles, criteria, standards, guidelines, and discharge planning processes, to analyze medical records concurrently for necessary and appropriateness of admissions and continued stays.
• Knowledge of nursing theory and practice and functional knowledge of microbiology and epidemiology.
• Knowledge of principles, practices, and procedures relating to all medical and surgical specialties, including care and treating seriously ill or injured patients.
• Knowledge of pertinent laws, regulations, mandates, policies, program goals and objectives, and operations of the organization under review.
• Comprehensive knowledge of alternative resources, such as Medicare, Medicaid, private insurance, and PRC program eligibility requirements, including knowledge of reimbursable insurance procedures and conditions and the ability to interpret provisions of individual health plans and group plans.
• Ability to facilitate, negotiate, and elicit cooperation as a team member.
• Ability to develop policies and procedures, plan, organize, assess and evaluate the meaning of data collected.
• Ability to prepare reports for presentation throughout the healthcare organization.
• Ability to communicate efficiently and effectively both verbally and in writing.

Minimum Qualifications:

• Associate's Degree in Nursing
• Current and unrestricted license as a professional nurse in a state of the United States of America.
• Two years of nursing experience in a clinical setting as a registered nurse.

Licenses, Certifications, Special Requirements:

• Bachelor's degree in Nursing preferred.
• Current and unrestricted state license as a professional nurse in the United States of America.
• Must have current certification in Cardio Pulmonary Resuscitation (CPR), Automated External Defibrillator (AED).
• Upon recommendation for hire, a criminal background and a National FBI fingerprint check are required to determine suitability for employment, including a 39-month driving record.
• May require possessing and maintaining a valid driver's license (no DUIs or major traffic citations within the last three years).
• If required, must meet the Tohono O'odham Nation tribal employer's insurance requirements to receive a driver's permit to operate program vehicles.
• Based on the department's needs, incumbents may be required to demonstrate fluency in both the Tohono O'odham language and English as a condition of employment.