RN Case Manager

Great Plains Tribal Health; Rapid City (SD); On-site; USD 68,000 - 88,000; Full time

Job summary

Great Plains Tribal Health seeks an RN Case Manager to coordinate patient care within a Medical Home model, assessing, planning, implementing, coordinating, monitoring, and evaluating care for assigned patients.

The role emphasizes care coordination across ED visits, hospitalizations, referrals, and identified gaps to improve outcomes, reduce avoidable utilization, and support patient self-management, while delivering direct nursing care as needed.

Qualifications

• Graduate of a state-approved RN program (ADN, diploma, or higher).
• Current RN license in good standing.
• Three (3) years of RN nursing experience or one (1) year RN experience and four (4) years LPN experience.
• Current Basic Life Support (BLS) certification.

Responsibilities

• Provide care coordination within a patient-centered Medical Home across lifespan.
• Assess, plan, implement, coordinate, monitor, and evaluate care for assigned patients.
• Coordinate care across providers, services, and community resources to ensure timely access and appropriate utilization.
• Support transitions of care after ED visits, hospitalizations, or changes in level of care.
• Document care coordination and outcomes in the electronic health record.
• Participate in quality improvement initiatives related to care coordination.

Skills

Care coordination

Patient education

Clinical decision-making

Education

Associate Degree in Nursing

Diploma or higher in Nursing

Tools

EHR systems

Population health tools

Job description

Position Summary

This position exists to support the organization’s mission, vision, values, and strategic priorities by providing patient-centered care coordination and care management within a Medical Home model. The Registered Nurse Case Manager is responsible for providing care in accordance with evidence-based care coordination principles. The RN Case Manager assesses, plans, implements, coordinates, monitors, and evaluates care for assigned patients.

Position Title: RN Case Manager

Division: Clinical Care

Reports to: Manager

Department: Varies

Position Summary

This position exists to support the organization’s mission, vision, values, and strategic priorities by providing patient-centered care coordination and care management within a Medical Home model. The Registered Nurse Case Manager is responsible for providing care in accordance with evidence-based care coordination principles. The RN Case Manager assesses, plans, implements, coordinates, monitors, and evaluates care for assigned patients.

This position focuses on coordination of care for patients following emergency department visits, inpatient hospitalizations, specialty referrals, and identified care gaps to promote continuity of care, improve patient outcomes, reduce avoidable utilization, and support patient self-management. The RN Case Manager collaborates closely with providers, community resources, and the Senior RN Case Manager to ensure patients with complex, high-risk, or escalating needs receive appropriate interventions and support across the continuum of care.

This role also provides direct nursing care as required by patient needs, care transitions, or staffing demands, ensuring safe, high-quality, culturally responsive care while supporting efficient use of healthcare resources and a seamless patient experience.

Essential Functions

The following functions are fundamental to the position and are required of all incumbents, with or without reasonable accommodation. These functions define the role and are not an exhaustive list of all duties.

• Functions as an RN Case Manager within a patient centered Medical Home, supporting coordinated, team based, whole person care across the lifespan (infant through older adult),.
• Manages assigned patient panels using panel and population health strategies, including risk stratification, care gaps, and follow-up needs.
• Utilizes population health tools, registries, and reports to monitor preventive care, chronic disease indicators, utilization trends, and outcomes.
• Conducts comprehensive assessments to identify medical, behavioral, psychosocial, and functional needs impacting patient outcomes and care coordination.
• Develops, implements, and evaluates individualized care plans for assigned patients
• Coordinates care across providers, service lines, and community resources to ensure timely access, continuity, and appropriate utilization of services.
• Supports transitions of care by coordinating follow-up after emergency care, hospitalizations, specialty visits, or changes in level of care.
• Maintains care coordination and tracking systems to ensure follow-through on referrals, diagnostics, testing, and treatment plans.
• Provides patient and family education focused on condition management, prevention, navigation of the healthcare system, and self-management strategies.
• Collaborates with providers and interdisciplinary team members to address barriers to care, adherence challenges, and social drivers of health.
• Applies clinical judgment and case management principles to prioritize needs, problem-solve complex cases, and elevate concerns appropriately.
• Provides direct nursing care as required by patient acuity, staffing needs, or care transitions, including assessments, interventions, and patient education across the lifespan (infant through older adult).
• Participates in multidisciplinary care conferences for patients with complex, high-risk, or population-based needs.
• Documents care coordination, population health activities, patient education, and outcomes accurately and timely in the electronic health record.
• Participates in quality improvement, utilization management, population health, and performance improvement initiatives related to care coordination.
• Serves as a clinical resource to team members regarding care management workflows, panel management strategies, and best practices.
• Maintains compliance with infection prevention, safety, privacy, and regulatory requirements.
• Participates in required meetings, training, competency validation, and continuing education; performs related duties consistent with licensure and role.

Minimum Requirements

• Graduate of a state-approved Registered Nursing (RN) program (Associate Degree in Nursing, diploma, or higher).
• Current Registered Nurse (RN) license in good standing
• Three (3) years of RN nursing experience or one (1) year of RN nursing experience and four (4) years of Licensed Practical Nursing experience
• Current Basic Life Support (BLS) certification.

Preferred Experience

• Experience in patient-centered Medical Home, care management models, or interdisciplinary team-based care.
• Familiarity with referral management and care transition workflows.