RN Care Coordinator (RN)

SDUIH; Sioux Falls (SD); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Holiday, PTO, Sick and Wellness Leave

Health, Dental and Vision Insurance

Life Insurance

Disability Insurance (Short/Long)

401(k) with company match

Job summary

SDUIH is seeking a Community Health Nurse to support the health and well-being of clinic populations and relatives experiencing barriers to care across SDUIH programs. The RN will collaborate with medical providers, nursing staff, and community partners to improve access to care, follow-up, and continuity of services.

Responsibilities include patient education, nursing services within scope, program development, care coordination, clinical documentation, and grant reporting.

Qualifications

• Must hold an active RN license in good standing.
• Experience in community health, STI prevention, chronic disease management, care coordination, or substance use treatment preferred.
• CPR certification or willingness to obtain within 30 days; Basic First Aid certification as required.

Responsibilities

• Provide culturally responsive nursing education and preventive health support to patients and relatives facing barriers to care.
• Coordinate referrals, appointments, and follow-up care with SDUIH staff and partners.
• Support grant-funded initiatives and quality improvement efforts; assist with grant reporting.

Skills

Care coordination

Community health

HIPAA compliance

EHR skills

Cultural humility

Education

South Dakota RN license

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

POSITION SUMMARY:

The Community Health Nurse supports the health and well-being of SDUIH’s current clinic population and relatives who experience barriers to accessing care, including but not limited to housing instability or homelessness. The position supports accessible, culturally responsive health services focused on prevention, screening, chronic disease management, and continuity of care across clinic and community settings.

The RN will collaborate with SDUIH medical providers, nursing staff, Community Health, Behavioral Health, and Cultural Health to improve access to care, strengthen follow-up, and support relatives in managing their health. Responsibilities include patient education, nursing services within the RN’s scope of practice, program development, care coordination, clinical documentation, and grant reporting.

The position supports grant-funded programming in collaboration with SDUIH staff and relevant clinical and program leadership. As community-based services develop, nursing activities will be carried out within the RN’s South Dakota scope of practice, demonstrated competence, applicable orders, and SDUIH-approved procedures and safety requirements.

DUTIES AND RESPONSIBILITIES:

1. Community-Based Nursing and Care Coordination: Provide culturally responsive nursing education, preventive health support, basic screenings, and care coordination to SDUIH patients and relatives experiencing barriers to health care.
   Recognize concerning screening results or changes in health status and facilitate timely provider evaluation or emergency response when indicated.
   Coordinate referrals, appointments, and follow-up care while collaborating with SDUIH staff and community partners to improve access to care and continuity of services.
2. Community Health Programming: Support grant-funded initiatives, including STI prevention, screening, testing and treatment coordination; diabetes prevention and management; and other approved community health initiatives.
   Coordinate health education, screening events, referral pathways, and follow-up activities with SDUIH staff and community partners.
3. Program Development and Quality Improvement: Help establish workflows, track program outcomes, support grant reporting and quality improvement, and explore opportunities to improve preventive health and chronic disease outcomes.
   Help to develop appropriate workflows, procedures, and safety requirements for community-based nursing activities.
   Collaborate with Behavioral Health on potential future SUD services.
4. Clinic Nursing Support: Assist with clinic nursing operations and staffing needs as assigned, following established clinical protocols and applicable provider orders.
   Follow established clinic procedures for infection prevention, specimen handling, medication administration, immunizations, documentation, and emergency response.
   Collaborate with clinic staff to maintain continuity of care and coordinate clinic and community responsibilities.
5. Clinical Safety, Professional Practice, and Accountability: Maintain an active South Dakota Registered Nurse license in good standing and practice within applicable nursing laws, regulations, professional standards, and SDUIH policies.
   Practice within demonstrated competence, seek clinical consultation when needed, and follow applicable provider orders, approved procedures, and escalation pathways.

Assess environmental and personal safety risks during community visits and follow SDUIH outreach safety procedures. Maintain patient confidentiality and protect health information in accordance with applicable law and SDUIH policies. Report incidents, safety concerns, and adverse events through established SDUIH reporting procedures. Complete required training and maintain competency in assigned nursing duties.

SCOPE OF PRACTICE:

• The RN will practice in accordance with SD nursing laws and regulations, the RN’s education and demonstrated competency, and SDUIH policies. The RN may provide nursing assessments, basic health screenings, health education, chronic disease prevention and management support, care coordination, and follow-up within the RN’s authorized scope of practice.
• The RN will support STI prevention, screening, testing, and treatment coordination; diabetes prevention, management; and coordination of access to substance use disorder treatment, including MAT, in collaboration with authorized healthcare providers.
• Community-based services may include blood pressure and blood glucose checks, health education, identification of health concerns, referrals, and coordination of follow-up care for relatives experiencing homelessness or other barriers to healthcare. The RN will use professional nursing judgment to identify concerns requiring further evaluation and will consult with or refer to an appropriate healthcare provider when needs exceed the RN’s scope or resources.
• All services must be provided within the RN’s scope of practice and in accordance with applicable requirements and SDUIH policies.

QUALIFICATIONS:

• Current Registered Nurse (RN) license in good standing through the South Dakota Board of Nursing, with no history of board violations or issues.
• Ability to pass required federal and organizational background checks and meet applicable SDUIH employment requirements. Must not have any felony convictions that relate to the Indian Child Welfare Act.
• Demonstrate professionalism, sound judgment, cultural humility, and the ability to work collaboratively with patients, staff, and community partners.
• Experience in community health, STI prevention and screening, chronic disease management, care coordination, or substance use treatment is preferred.
• CPR certification or willingness to obtain certification within 30 days of employment; current Basic First Aid certification, as required by SDUIH.

KNOWLEDGE, SKILLS, AND ABILITIES:

• Knowledge of local, state, federal, and community resources for patient care and support.
• Knowledge of current documentation and coding practices, including applicable ICD-10-CM and CPT requirements.
• Knowledge of applicable HIPAA, OSHA, infection-prevention, and patient-safety requirements.
• Ability to provide patient education related to acute and chronic health needs and preventive health measures.
• Ability to coordinate care and services with community agencies and partners.
• Ability to maintain accurate records, prepare reports, prioritize tasks, coordinate appointments, and use EHR (electronic health record) and other required systems.
• Ability to travel and participate in required training sessions, team meetings, community events, and outreach activities.
• Ability to maintain a flexible schedule, including occasional evenings and weekends, based on program needs.

STANDARD REPORTING REQUIREMENTS:

• Complete required documentation and reporting in the EHR and other designated systems.
• Assist with grant reporting, program outcome tracking, and specialized reports as requested by the Grants Director and leadership.
• Complete applicable reporting for assigned grant-funded activities, SDUIH quality improvement programs, STI and immunization programs, and other assigned services, as applicable to the position.
• Maintain records and reports in accordance with applicable nursing standards, program requirements, and SDUIH policy.

PHYSICIAL DEMANDS:

• Involves direct and frequent contact with potentially unstable clients.
• Involves direct contact with clients who may have infectious diseases.
• The employee must follow applicable infection-prevention, personal safety, and field outreach procedures and be able to perform the essential functions of the position with or without reasonable accommodation.

LICENSES AND CERTIFICATIONS:

• Licensed by the South Dakota Board of Nursing as a Registered Nurse (RN) in good standing.
• CPR certification or willingness to obtain within 30 days of employment.
• Basic First Aid certification, as required by SDUIH.

OTHER DUTIES AND EMPLOYMENT CONDITIONS:

Perform other duties consistent with the position’s qualifications, scope of practice, and organizational needs as assigned. SDUIH reserves the right to amend this job description as operational needs dictate. SDUIH is an at-will employer.

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