Nurse Specialist (Case Management

PLEASE NOTE - This position may require temporarily relocation to other TONHC Facilities:
Sells Hospital, Santa Rosa Health Center, San Simon Health Center, and San Xavier Health Center.

The Nurse Specialist (Case Management) (NCM) provides outpatient case management and self‑management education to persons with chronic disease and special healthcare needs. Other duties include assisting with the planning and implementation of community‑based prevention and education activities.

The NCM serves a vital role within the primary care team. Knowledge of the community, understanding the obstacles patients face to receive care, and being flexible and resourceful are critical attributes needed to navigate the ever‑changing healthcare system. Additionally, the NCM often assists in addressing and resolving social issues of the patients and families served. Occasionally, the NCM provides services for an entire family as a relationship of trust develops, and people become more likely to return for additional assistance when needed.

This position is located within TONHC and serves in the ambulatory care setting. It may be situated organizationally in TONHC Sell hospital or any TONHC health centers. The NCM works under the general supervision of the Clinical Director, who provides administrative oversight. The incumbent functions with considerable independence in coordinating with care teams and performing case management duties.

(Depending on the area of assignment, an incumbent may not be required to perform some of the duties listed below):

• Works alongside the primary care team to assist individuals in promptly accessing needed specialty medical care.
• Problem‑solves multiple obstacles to care for patients and families facing complex health problems in various socioeconomic contexts.
• Provides care coordination for persons with specialized and complex healthcare needs.
• Educates patients and families regarding the recommended services, their expected benefits, risks, and alternatives.
• Facilitates scheduling of the specialty appointments and ensures transportation to and from is arranged.
• Follows up to verify appointment attendance and obtains visits, procedures, and test reports for the patient's medical records.
• Ensures the primary care team is aware of test results, treatments, and consultants' recommendations.
• Connects the patient/family with appropriate resources by referral to community services for which they may be eligible, including programs within and outside the Tohono O'odham Nation.
• Monitors progress, condition, and discharge plan for TONHC beneficiaries hospitalized in and outside Tucson, Casa Grande, and Phoenix facilities.
• Provides information to primary care teams to ensure the client receives hospital discharge follow‑up in a timely manner to decrease hospital readmissions.
• Conducts chart reviews of patients whom NCM follows.
• Fields inquiries via incoming calls regarding services available at TONHC.
• Follows up and attends scheduled clinic visits with patients followed by NCM.
• Assists with scheduling specialty appointments, including entering referrals and faxing documents needed for transportation.
• Assists with scheduling transportation for medical appointments.
• Performs task‑oriented work based on patient needs.
• Communicates with patients and families in person, by phone, or by correspondence.
• Frequently communicates with specialty schedulers within the TONHC referral network and with local community partners.
• Communicates with Community Health Representatives and Home Health Nurses to contact difficult‑to‑reach patients and families and obtain useful clinical reports.
• Attends community events to share information about services available to TONHC.
• Reviews area hospital admissions via remote access for TONHC beneficiaries and communicates relevant information to the primary care team.
• Compiles a listing of beneficiaries discharged from area hospitals or transferred to area hospitals from the Sells ER or TONHC ambulatory clinics.
• Coordinates weekly conference calls among all Clinical Nurse Team Leaders, Social Work Services, and TON Home…