Registered Nurse (Ambulatory Care Case Management)

Salary: $80,036.00 - $110,054.00 Annually
Location : Scottsdale, AZ
Job Type: Full-Time
Job Number: 100369-250423
Department: Health & Human Services
Opening Date: 04/23/2025
Closing Date: 5/23/2025 11:59 PM Arizona

Definition
Position Summary: Under the supervision of the Transition Ambulatory Care Case Management RN Supervisor (TACCMRNS). The Ambulatory Care Case Management RN will manage Low to Moderate Risk patients that have been identified, screened, and assessed for planning, implementation, coordination, monitoring and evaluation of healthcare services. The goal of the Ambulatory Care Case Management RN is to optimize patient outcomes, enhance the patient experience, and increase the delivery of recommended preventative services. This job class is treated as FLSA Non-Exempt.
Essential Functions: Essential functions may vary among positions and may include the following tasks, knowledge, abilities, skills and other characteristics. This list of tasks is ILLUSTRATIVE ONLY and is not intended to be a comprehensive listing of tasks performed by all positions in this classification.

Examples of Tasks

1. Ambulatory Care Case Management: Identifies low to moderate risk patients, ensures access to appropriate care, provides case management services and facilitates utilization of these services by reviewing data submitted through referral sources and applies appropriate criteria and standards in screening patients for Ambulatory Care Manager RN services.

Manages patients in single disease management to reduce risk of hospitalization and/or progression to Chronic Care Management.

Assesses and analyzes patient data in order to identify actual and potential problems or needs.

Documents and prioritizes goals and interventions according to actual or potential concerns of the patient.

Develops and facilitates an individualized, comprehensive and evidence-based plan of care in collaboration with the care team, patient and caregivers to optimize the patient's treatment, care and functional outcomes.

Utilize care management principles and utilization of systems and community resources tailored to meet an individual patient needs.

Engaging the patients and their caregivers in understanding and learning in the management of their diagnoses, treatment, and symptoms.

Identifies member needs as well as barriers to care and available resources while caring for the patient in the most cost/quality efficient environment possible to implement cost management strategies.

Monitors and evaluates the services being provided with frequent updates to the care plan as necessary and coordination of care including the patient and healthcare team.

2. Multidisciplinary Care Coordination: Follows established policies, procedures and standing orders.

Follows patients through the care continuum and collaborates with other members of the health care team to ensure continuity of care and implements the agreed plan of care.

Consults with physicians and other health care providers regarding patient specific clinical, social and behavior health related issues and educational needs.

Facilitates timely and appropriate referrals and fosters positive relations with community providers and partners.

Participates in patient care conferences including but not limited to hospital, clinic, home health care, SNF/LTC, etc. as well as specialty team meetings as required by Health Plans for individual groups of members and/or eligibility status (i.e., Special Needs, Individual Education Plan, Disability, etc.) by preparing and completing required documents.

Maintains professional knowledge and proficiency in nursing through continuing education, staff meetings, training and conferences, etc.

Participates in the data collection efforts to track outcomes.

3. Performs other duties as assigned to maintain and enhance the health care program and Department of Health and Human Services service operation.
Knowledge, Skills, Abilities and other Characteristics:

• Knowledgeofthehistory,culture,laws,rules,customsandtraditionsoftheSRPMIC.
• Knowledgeofthepurpose,currentissues,projects,organization,policies,andemployeeresponsibilities ofthedivisionto whichassigned.
• Knowledge of theory, principles and scope of practice for a Licensed Registered Nurse.
• Knowledge of federal, state, and agency laws and regulations governing professional nursing.
• Knowledge of health systems and disease processes.
• Knowledge of medical, public health and social service resources available to Native Americans including, but not limited to, Indian Health Service, Medicare, Medicaid, ALTCS, SSI, etc.
• Knowledge of electronic health records and community resources.
• Knowledge of CMS, AHCCCS, and commercial payer requirements as well as care coordination and resource management in ambulatory care settings.

• Skill in using electronic health record systems and other healthcare software for accurate documentation and information retrieval.
• Skill with strong organizational and time management to prioritize tasks and manage medical services referrals effectively.
• Skill with verbal and written communication and ability to communicate effectively with a wide range of people, correctional facility staff and health professionals.
• Skill applying and interpreting federal, state, and agency laws and regulations governing practical nursing.
• Skills to effectively educate, counsel, and advocate for patients and their families.
• Skill with advanced customer service and excellent problem-solving.

• Ability to use critical thinking and to problem solve in a professional manner.
• Ability to work collaboratively and proactively with healthcare teams and other hospital-based interdisciplinary teams.
• Ability to apply empathy and compassion to provide emotional support and address the needs of patients.
• Ability to lead and proactively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff.
• Ability to establish and maintain positive working relationships with colleagues, subordinates, supervisors, health care professionals, Tribal officials, detainees and representatives of resource agencies.
• Ability to incorporate cultural differences, health beliefs and learning styles.
• Ability to maintain confidentiality.
• Ability to operate a variety of standard office equipment including cellular phones, photocopiers, FAX machines, calculators and personal computers including MS Office.

Minimum Qualifications

• Education and Experience: A degree in Licensed Registered Nursing from an accredited college or university and certification as a Licensed Registered Nurse (RN) required.

• Arizona Registered Nurse license required.
• Minimum of 1 - 2 years of experience including Primary Care Case Management preferred
• Two years of clinical nursing experience in acute care or outpatient setting preferred
• Certification as a Certified Case Manager (CCM) preferred or ability to obtain within 18 months of hire.
• Experience working with Native American Communities preferred.

• Equivalency: Any equivalent combination of education and/or experience that would allow the candidate to satisfactorily perform the duties of this position, will be considered.

• Underfill Eligibility: An enrolled Community Member whom closely qualifies for the minimum qualifications for a position may be considered for employment under SRPMIC Policy 2-19, Underfill.

Special Requirements

• Employment is contingent upon successful completion of an extensive background check and drug screening. Employees in, and applicants applying for, jobs providing direct services to children are subject to the "Community Code of Ordinances", Chapter 11, "Minors", Article X. "Investigation of Persons Working With Children".

Prior to hire as an employee, applicants will be subject to drug and alcohol testing. Will be required to pass a pre-employment background/fingerprint check.
"SRPMIC is an Equal Opportunity/Affirmative Action Employer" Preference will be given to a qualified: Community Member Veteran, Community Member, Spouse of Community Member, qualified Native American, and then other qualified candidate.
In order to obtain preference, the following is required: 1) Qualified Community Member Veteran (DD-214) will be required at the time of application submission 2) Qualified Community Member (must provide Tribal I.D at time of application submission),3) Spouse of a Community Member (Marriage License/certificate and spouse Tribal ID or CIB is required at time of application submission), and 4) Native American (Tribal ID or CIB required at time of application submission).

Documents may be submitted by one of the following methods:

1) attach to application

2) fax (480) 362-5860

3) mail or hand deliver to Human Resources.

Documentation must be received by position closing date.

The IHS/BIA Form-4432 is not accepted.

Your Tribal ID/CIB must be submitted to HR-Recruitment-Two Waters.
The SRPMIC offers a comprehensive benefit package including medical, dental, vision, life, disability insurance, and a 401(k) retirement plan. In addition employees enjoy vacation and sick leave and 13 paid holidays.