Summary: The Public Health Case Manager functions as an integral member of the medical and behavioral health departments with the aim of improving self-management and clinical outcomes for patients of San Diego American Indian Health Center. The PH RN Case Manager will plan, organize, and coordinate care, targeting individuals at the highest risk and ensuring integrated flow of services. The Case Manager will be responsible for panel and case (individual) management of patients and will work in close proximity with the primary care and behavioral health teams to achieve the desired outcomes.
Essential Duties and Responsibilities:
Support of the mission of the Indian Health Service 4-in-1 grant: support health promotion and disease prevention programming, immunization services, substance abuse related services, and behavioral health services. Aim is to specifically link these services to the larger infrastructure of the health center to address specific service gaps that may exist. Participate in patient outreach strategy designed to increase the utilization of the health center's medical services among urban American Indian/Alaskan Natives, resulting in an increase of unduplicated eligible beneficiaries receiving primary care and/or preventive services.
Manage the Immunization Services Program, including: a) participation in Vaccines for Children (VFC) and older adult vaccine programs; b) implementation of health promotion strategies in collaboration with Medical Team designed to increase overall coverage rates; c) work in collaboration with Data Analytics Team to prepare and submit quarterly reports to the National Immunization Reporting System (NIRS).
Collaborate with the Chief Medical Director/Behavioral Health Director to ensure that processes are in place to collect and evaluate behavioral health screenings (including depression, tobacco, alcohol, and intimate partner violence screens) among primary care patients and manage referrals as appropriate to the behavioral health department or case manager, and other internal Providers and resources.
Work in collaboration with Medical Team to assess mid-year GPRA results each year to identify underperforming clinical performance measures that may be improved through implementation of evidence-based strategies to achieve the IHS national targets by the end of the GPRA reporting period (9/30). Utilization of electronic health record (eClinical Works (eCW) ) to collect and manage data for the patient registries.
Ensure services meet guidelines for Government Performance and Results Act (GPRA), Patient-Centered Medical Home (PCMH), Accountable Care Organization (ACO), Health Resources Services Administration (HRSA) and other quality performance initiatives.
Work in collaboration with Providers and Clinical Coordinator to determine at-risk Native and Non-Native patients. Actively contact these patients to set up RN case management appointments. In conjunction with patient, identify patient preferences and functional lifestyle goals, treatment goals, address potential barriers. Set attainable goals using evidence-based practice as the foundation while addressing gaps and /or barriers to care. These patients include at-risk Native patients to deliver Coastal Roots Farm produce bags to monthly.
Participate in the Diabetes Prevention Program.
Provide member education to assist with self-management goals. Identify barriers to self-management, such as transportation, and collaborate with appropriate staff to make arrangements accordingly.
Active involvement in the community to educate about risk factors for chronic disease, increase community-based screening methodologies, and recruit newly diagnosed individuals to SDAIHC for treatment and management.
Adhere to organizational and departmental policies and procedures.
Perform the clinical and administrative duties necessary to meet the goals and objectives of the grant.
Other duties as assigned by the Medical Director.
Serve as back-up to Clinic Nurse. Support Medical Team as needed with Triage Calls and staff shortage.
Supervise and assist PrEP Navigator/ Wellness Coordinator with Outreach Events and patient care.
Qualifications:
Education and/or Experience: Public Health Nursing Degree AND Bachelor's degree in nursing from a four year college or university (RN).
Ability to view the patient as a whole person within the context of their family and community.
Behavioral counseling experience.
Excellent interpersonal and communication skills.
Computer and analytic skills to run reports and review data.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Knowledge of utilization management, quality improvement and cost management
The SDAIHC client experience includes using AIDET to develop a strong connection with our patients/clients.
Acknowledge: Greet the patient/client by name. Make eye contact, smile, and acknowledge family or friends in the room.
Introduce: Introduce yourself with your name, skill set, professional certification, and experience. Managing yourself and your colleagues up instill confidence that our patients/clients are in the best place to receive care.
Duration: Give an accurate time expectation for tests, physician arrival, and identify next steps. When this is not possible, give a time in which you will update the patient on progress. When wait exceeds expectation continue to check in with patient/client.
Explanation: Explain step-by-step what to expect next, answer questions, and let the patient/client know how to contact you, such as a extension or phone number.
Thank You: Thank the patient and/or family. Express gratitude to them for choosing SDAIHC for their care, and you appreciate them placing their trust with us. Thank family members for being there to support the patient.
Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The employee is frequently required to stand, walk, sit, reach with hands and arms, climb, balance, stoop, kneel, crouch, or crawl. The employee must regularly lift and/or move up to 10 pounds, frequently lift and/or move up to 25 pounds.
Acknowledgement: The San Diego American Indian Health Center is an Equal Opportunity Employer. We encourage applications from all individuals regardless of race, religion, color, sex, pregnancy, national origin, sexual orientation, ancestry, age, marital status, physical or mental disability, or any other protected class, political affiliation, or belief. Indian preference is given to qualified American Indian candidates to fill vacancies in accordance with the Indian Preference Act of 1934 (Title 25, USC Section 472).