RN Care Navigator: Medical Home & Transitions

Great Plains Tribal Leaders Health; Rapid City (SD); On-site; USD 49,000 - 74,000; Full time

Job summary

Great Plains Tribal Leaders Health is seeking an RN Case Manager in Rapid City, SD to provide patient-centered care coordination within a Medical Home model. The role emphasizes evaluating patient needs, developing care plans, and coordinating across providers to improve outcomes.

You will work with an interdisciplinary team to monitor follow-up, support transitions, and promote self-management while maintaining high-quality, culturally responsive care.

Qualifications

• RN Case Manager coordinates care across the Medical Home model.
• Performs comprehensive assessments to identify medical, behavioral, psychosocial, and functional needs.
• Develops and evaluates individualized care plans for assigned patients.
• Coordinates care across providers and community resources to ensure timely access and appropriate utilization.
• Maintains care coordination and tracking in the electronic health record (EHR).

Responsibilities

• Coordinate care after emergency department visits, hospitalizations, or specialty visits.
• Support transitions of care and follow-up activities to reduce avoidable utilization.
• Educate patients and families on condition management and self-management strategies.
• Collaborate with providers and interdisciplinary teams to address barriers to care.

Skills

Care coordination

Patient education

Clinical judgment

Collaboration

Population health

Education

Associate Degree in Nursing (ADN) or higher

Job description

Great Plains Tribal Leaders Health is seeking an RN Case Manager in Rapid City, SD to provide patient-centered care coordination within a Medical Home model. The role emphasizes evaluating patient needs, developing care plans, and coordinating across providers to improve outcomes.

You will work with an interdisciplinary team to monitor follow-up, support transitions, and promote self-management while maintaining high-quality, culturally responsive care.