Job Description

Job Location: Santa Rosa - Santa Rosa, CA 95401,

Position Type: Full Time, Education Level: 2 Year Degree,

Salary Range: $42.65 - $72.38 Hourly,

Job Shift: Day,

Job Category: Health Care, POSITION SUMMARY:

Under direct supervision of the Nursing Manager, the RN Case Manager is an integral member of the clinical Care Team, primarily supporting providers and patients through comprehensive nursing case management services. This role delivers personalized, patient-centered care coordination for individuals with chronic or complex conditions—such as diabetes, COPD, and heart disease—by identifying and addressing barriers to care. Working collaboratively within a multidisciplinary team, the RN Case Manager promotes improved health outcomes by empowering patients in self-management, enhancing care continuity, and supporting effective use of healthcare resources.

ESSENTIAL FUNCTIONS

• Work as part of the clinic nursing team to provide a full range of nursing services including floor nursing, patient triage, phone advice, case management, Care Team coordination, and patient education.
• Work closely with the Primary Care Provider and clinical Care Team in providing nurse case management which may include:
• Coordination of care within Primary Care Team.
• Proactive management of patients with chronic illnesses with poor clinical outcomes or with complex healthcare needs.
• Assist patients in care management and system navigation with recent critical diagnosis.
• Manage critical abnormal lab/DI results.
• Provide management for patients discharged from ER and inpatient setting.
• Active participation in Care Team’s high risk case management.
• Provide home visits as indicated.
• Work closely with Primary Care Provider to manage patient “Care Items” which could include medication refills per protocol, lab results, triage, document management, management of durable medical equipment, or other services, and other items as needed.
• Coordinate population management of Care Team patient panel.
• Assist patients in obtaining appropriate medications and other medical supplies and equipment including coordination of Pharmaceutical Patient Assistance programs.
• Participate in patient and staff education.
• Provide nurse visits for designated conditions per clinical protocol.
• Coordinate Care Team support for patients with new health management goals.
• Coordinate tracking of patients for follow-up and continuity of care which may include:
• Developing and using practice guidelines and protocols.
• Use of flow sheets, problem lists, and medical data bases.

c) Development and use of critical pathways.

d) Tracking outcomes and reporting to primary care provider.

e) Tracking and expediting referrals.

• Assist with discharge planning / home care referrals.
• Collaboration with the Mental Health Team for intervention services for clients who are overwhelmed by an acute episode, or for those others who have limited self-care abilities.
• Oversee Care Team Medical Assistant administration of immunizations and medications, both injection and oral within the office visit.
• Completes patient assessment/intake including chief complaint, vital signs, height and weight.
• Supervision of and acts as resource for Medical Assistants in the clinical Care Team.
• Anticipates the needs of the providers whenever possible.
• Ensures that health maintenance needs are reviewed with provider; is aware of age specific screening, GPRA indicators, diabetic health recommendations.
• Carries out health maintenance procedures as allowed by standardized procedures.
• Administers immunizations per provider order; must be cognizant of immunization schedule through CAIRS and California Department of Public Health (CDPH). Ensures correct needle size, length, site, route are adhered to; verifies/double checks with provider.
• Assists providers with procedures and pelvic examination as requested.
• Perform electrocardiograms (EKG) as directed by the provider.
• Administers medications as directed by the provider; verifies drug, dosage, and allergy status prior to administration.
• CPSP activities; may be involved with special projects.
• Ensure lab specimens (those sent to the outside lab) are properly processed including paperwork.
• Assists providers with paperwork and collection of records needed to ensure quality patient visits.
• Ensure exam rooms and other designated areas in the Medical Department are stocked appropriately with supplies, literature, as needed.
• Cleans exam rooms after each patient and at the end of the day.
• Checks expiration dates for supplies and medications as outlined in Nursing Responsibilities and disposes of expired items via pharmacy, lab or Nursing Director.
• May act as “late Nurse” to complete clinic day.
• Adheres to Blood borne Pathogen Control Plan and disposes of sharps per protocol.
• Ensures expedient return of health records to Health Information Department (HIM) per protocol.
• Maintains patient confidentiality at all times; abides by HIPPA and other regulations put forth by the various regulatory agencies.
• Knowledge with referrals internals and externals per protocol.
• Triage patients in person and on the phone, competency and response to medical emergencies.
• Sterile pre-processing.
• Policy and procedure writing and adjustment as needed.
• Performs other duties as assigned.

Qualifications: EDUCATION AND EXPERIENCE:

• Graduate of accredited school of Nursing.
• Current unrestricted License to practice nursing in the state of California.
• One to two years of clinical nursing experience preferred.
• Possess current CPR certification.
• Able to operate fax machine, copier, telephone and compute, and EHR (EPIC preferred).
• Able to operate EKG, microscope, centrifuge, glucometer, nebulizer, Cholestech, HgA1c and Clinitek machines.

QUALIFICATIONS

• Reliability and punctuality is necessary.
• Ability to work well within a multidisciplinary team.
• Must comply with all federal, state and local laws and regulations, and SCIHP policies.
• Required to have versatility, flexibility and a willingness to work within constantly changing priorities with enthusiasm and positive attitude.
• Able to work independently with little or no supervision.
• Demonstrate a positive customer service, patient centered approach at all times.

SPECIAL QUALIFICATIONS

All employees must be sensitive to the needs of the Native American community, demonstrate a deep understanding and respect for the diverse cultural heritage, traditions, and historical context of the Native American community.

Apply to: Sonoma County Indian Health Project, Inc.

Attn: Human Resources Department

144 Stony Point Road, Room 2209, Santa Rosa, CA 95401

Fax (707) 526-1016 or Email Resume and SCIHP Application to: employment@scihp.org

Employment Application available online at: www.scihp.org/human-resources

When applying for Indian Preference, attach valid proof of eligibility