Under general supervision of the Chief of Mental Health (MH)/Psychiatrist, the RN Case Manager will work independently in conjunction with multidisciplinary team members involved in the care of pediatric, adolescent, adult, and geriatric patients with mental and emotional disorders at the Dilkon Medical Center (DMC) and other Winslow Indian Health Care Center (WIHCC) sites as necessary. The position will be responsible for coordinating and assuring the provision of appropriate, timely, and beneficial care for patients by promoting quality and cost-effective health care outcomes in a seamless continuum of care. This will be accomplished by working within established standards for clinical care coordination, case management principles and advance access principles.
This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.
Essential Duties & Responsibilities:
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Works in conjunction with licensed mental health providers, medical practitioners, and other healthcare personnel to provide support, counseling, assessment, crisis intervention, referral, and coordination of services for psychiatric patients in accordance with standards established by WIHCC/DMC, Indian Health Service, and relevant national accreditation organizations. Services are to be provided to patients with a wide variety of acute and chronic mental health problems including depression, bereavement, psychosis, behavioral dyscontrol, family conflicts, substance abuse or dependence, and trauma resulting from violence or abuses of emotional, physical or sexual nature.
- Provides services primarily at the Dilkon Medical Center Mental Health Department; but will also work remotely, and at times on-site with MH staff in Winslow and Leupp clinics; and upon request interviews WIHCC beneficiaries in outside facilities, e.g. Little Colorado Medical Center (LCMC) in order to facilitate care in crisis situations. In crisis cases, works with licensed medical providers to facilitate appropriate intervention and to assist in placement and follow-up arrangements when necessary.
- Provides services in support of direct care to MH patients as needed under protocols approved by MH Director and Chief Medical Officer, including psychotropic medications and injections when ordered by licensed providers.
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Works closely with the Navajo Nation Division of Social Welfare and other agencies to coordinate services for patients who are reported for suspected child abuse/neglect. Develops and maintains effective liaisons with the courts, social services and medical community for the benefit of abused and neglected (SCAN) patients.
- Conducts home visits when necessary for the purposes of providing supportive and case management services to individuals and families in need of services and/or follow-up.
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Works with patients in clinical settings or at homes to maximize benefits of treatment plans established by mental health professionals at WIHCC. Implements strategies to enhance adherence with appointments, medications, and other treatment recommendations. Assists patients with transportation needs, interpersonal issues, and financial and legal issues as necessary.
- Works actively with Navajo Nation Regional Behavioral Health Authority (RBHA) and with WIHCC Patient Benefits Coordinators to assure eligibility determination and enrollment in benefits programs as appropriate.
- Works collaboratively with and refers to the appropriate departments and clinical staff at DMC and WIHCC, including Medical Clinics, Emergency Department, Urgent Care, Maternal Child Health, RN Care Coordinators and Pediatric Care Coordinator, Public Health Nursing, Nutrition Service, WIC, Traditional Healing Program, Massage Therapy, Little Colorado Medical Center and outside specialty consultants, as well as other facilities providing health care and support services for WIHCC patients.
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Develops and maintains internal patient care database for continuous tracking and follow up for continuity of care for active management of patients assigned.
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Integrates factors related to quality, safety, efficiency, and cost effectiveness in planning, delivering, monitoring and evaluating patient care by promoting the most effective and efficient use of human and financial resources.
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Maintains compliance with applicable laws, such as patient confidentiality, abuse reporting, principles of consent and advanced medical directives.
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Advocates for the patient/family at the service-delivery level and at the community level fostering the patient’s/family’s decision-making, independence, and growth and development.
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Utilizes best practice model to identify, develop, and implement such practices for mental health case management.
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Assists in coordinating and tracking referrals in conjunction with WIHCC providers and outside specialists, and collaborates closely with the Inpatient and Outpatient RN Case Managers in CHS.
- Functions as liaison for patients and providers by monitoring scheduled clinic appointments, referrals for placement, and diagnostic studies and procedures, such as CTs, MRIs, and other specialized testing; works to ensure travel and accommodations are arranged as needed for patients. Notifies provider when necessary consultations, studies, or placements fail to be accomplished and works on mitigating barriers.
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Communicates with courts and law enforcement as necessary to assure patients receive necessary treatment, and that the mental health system and legal system work together appropriately to achieve optimal outcomes while assuring public safety.
- Upholds all principles of confidentiality and patient care to the fullest extent.
- Assists when needed in counseling of patients and crisis intervention, referring to appropriate providers as indicated.
- Performs chart reviews for high risk patients, identifies needs, monitors and tracks adherence to treatment plan and appointments; and communicates with providers in order to develop effective interventions.
- Works closely with the MH staff to establish and maintain an accurate registry for patients with suicide attempts and or recent hospital admissions; to actively track such patients and follow up on them when they have not been seen according to standards of care, policy, or individualized patient needs.
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Develops case management guidelines and policies relevant to mental health issues.
- Provides individual and group education to relevant staff as necessary and/or requested by team members on mental health issues.
- Interacts in an honest, trustworthy and dependable manner with patients, employees and vendors.
- Possesses cultural awareness and sensitivity.
- Maintains regular attendance and punctuality.
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Performs other duties as assigned by the supervisor consistent with the position and in compliance with WIHCC policies and procedures.
Minimum Qualifications:
Requires completion of an accredited nursing program and an unrestricted license as a Registered Nurse. Advanced experience as a Registered Nurse is required. Minimum of one year of clinical experience working in general out-patient healthcare services; experience in mental health field preferred. Current BLS/CPR required. Bilingual skills in English and Navajo language preferred. Must maintain a valid unrestricted and insurable driver’s license. Must successfully pass a background investigation and maintain suitable requirements for a Child Care position. This position is considered as a Child Care position, which requires a satisfactory background check investigation and is subject to the requirements of the Indian Child Protection and Family Violence Prevention Act, as amended (henceforth referred as the ICPFVP Act).
Knowledge, Skills, Ability
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Ability to be dependable in attendance and job performance.
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Ability to meet attendance and other reliability requirements of the job, including the need to work additional hours when needed to accomplish objectives.
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Knowledge of basic human development through the life span; familiarity with mental and emotional disorders and substance use disorders, and their effect on individuals and families.
- Knowledge of scope of patient care services provided by other clinical service lines and the referral process.
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Knowledge of effective teaching processes & principles in planning, providing & evaluating optimum health care.
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Knowledge of quality management and improvement processes to comply with internal and external accreditation standards (AAAHC, CMS, etc).
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Knowledge of clinic practices and ability to act as a resource for clinic personnel.
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Knowledge of EHR, RPMS, iCare, and other WIHCC software programs in the performance of patient care and coordination, including Microsoft Office and Outlook applications; ability to navigate and adapt to computer systems efficiently.
- Knowledge of documentation standards and ability to accurately and completely document clinical data relating to the patient and/or family.
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Knowledge of, and sensitivity to, cultural and language differences.
- Knowledge of interpersonal skills in handling interactions with clinical staff, other agencies, groups, and patients and families.
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Ability to work as a team member and develop productive and cooperative working relationships with health care providers within and external to WIHCC; ability to interact effectively with judicial and law enforcement agencies.
Physical Demands:
While performing the essential functions of this position, the employee is regularly required to walk, sit, use hands to handle and manipulate objects and equipment, reaches with hands and arms, and communicate effectively verbally and audibly. The employee frequently must stand, climb, balance, stoop, kneel, crouch, or crawl and may occasionally use taste or smell. The employee must occasionally lift and/or move objects weighing up to 50 pounds.
Work Environment:
Work is performed in an office setting or outdoor work environment with moderate noise levels. Work environment may involve exposure to physical risks, such as blood borne pathogens, hazardous chemicals, or operating potential dangerous equipment, and requires adherence to all safety protocols. Required work schedules may include evening, weekend, overnight shifts, extended hours, or irregular schedules and rotation as operational needs dictate.
As required by P.L. 93-638, absolute preference will be given to qualified Navajo applicants. If there is no qualified Navajo applicant, preference will be given to qualified American Indian applicants.
