Navajo Preference Employment Act
Navajo Nation and federal law compliance: TCRHCC has implemented an Affirmative Action Plan pursuant to the Navajo Preference in Employment Act. Applicants who meet the necessary qualifications for this position will be given preference in hiring and employment as follows: (1) enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe; (2) those legally married to enrolled members of these tribes and who meet residency requirements will receive secondary preference; (3) enrolled members of other federally-recognized American Indian Tribes will receive tertiary preference.
Overview
POSITION SUMMARY
Incumbent serves as an Outpatient/Inpatient Case Manager/Utilization Review Registered Nurse (CM/UR RN) for TCRHCC and is responsible for direct supervision and supportive contact for the specific group of identified patient assignments and high-risk patients. The CM/UR RN designs and manages a continuum of care focusing on empowering clients to achieve demonstrable outcomes and self-sufficiency. The CM/UR RN conducts assessment, service planning, resource acquisition, monitors progress, and responds to emerging client needs. The CM/UR RN performs Utilization Review and Management/Clinical Documentation Chart Reviews in acute clinical care and ambulatory care settings and conducts UR reviews as required. The CM/UR RN works closely with the Social Work (MSW) Case Manager on Discharge Planning and Care Transitions, with the Physician Advisor, and participates on the UR Committee. The CM/UR RN conducts Clinical Documentation Chart Reviews related to peer review, financial or insurance determinations, or claims denials. The CM/UR RN connects clients with Community Social Service providers, health care, substance abuse, and mental health providers to achieve goals. The CM/UR RN will have experience with culturally diverse low-income populations facing barriers to self-sufficiency (e.g., illiteracy, welfare dependency, domestic violence, substance abuse, mental health issues) and will work with a multidisciplinary team. The CM/UR RN collaborates with Purchased and Referred Care (PRC) and provides assistance with the PRC Case Specialist. The CM/UR RN reports to the Director of Care Coordination.
The CM/UR is responsible for compliance with CMS Conditions of Participation regarding Utilization Review and Discharge Planning, including implementation and annual review of the Utilization Management Plan, and coordinating the Utilization Management Committee. The CM/UR ensures compliance with Joint Commission and Federal/state regulatory requirements. It ensures that care after discharge or transfer meets patient needs. The CM/UR follows the hospital's Case Management/Utilization Program integrating utilization review, discharge planning, and resource management to provide care in the most appropriate setting with medically indicated resources. The hospital’s case management model emphasizes collaboration to improve quality through coordination of care, impact on length of stay, cost minimization, and optimal outcomes.
Qualifications
NECESSARY QUALIFICATIONS
Education: Associates Degree in Nursing; must obtain a bachelor’s in nursing within two (2) years of hire
License/Certification:
A valid, current, full and unrestricted Professional Nursing License to practice as an RN in any state, the Commonwealth of Puerto Rico, or a U.S. territory
Must have and maintain current Basic Life Support (BLS) certification by the American Heart Association throughout employment
Experience:
Three (3) years of clinical nursing experience with direct patient care; at least 2 years in an inpatient medical-surgical unit, PACU, higher acuity unit (ICU, Step-Down, Telemetry, etc.) or home health (direct care). Clinical experience qualifications may be determined by the hiring manager/director.
Demonstrate knowledge of case management, purchased/referred care, and utilization review
Demonstrate knowledge of electronic health record systems
Other Skills and Abilities:
A record of satisfactory performance in prior and current employment evidenced by positive references addressing:
Positive working relationships with others
High ethical standards and no history of complaints
Reliable and dependable; punctuality and attendance
Effective verbal & written communication
Team management focus promoting proactive problem resolution
Successful completion of and satisfactory performance in interviews
Successful completion of background checks and fingerprint clearance
Submission of required employment documents free of misinformation
Mental and Physical Effort
The physical and mental demands described are representative of those required to perform essential job functions. Reasonable accommodation may be made for disabilities.
Physical: High energy, long and flexible schedule; sitting, computer work, walking for staff interactions; bending, kneeling, crouching, twisting, balance; hearing and speaking ability; ability to lift up to 50 lbs; vision and hearing requirements; keyboard use.
Mental: Independent judgment, analytical skills, ability to work in structured and unstructured environments, attention to detail, ability to handle multiple priorities in stress, patient and calm decision-making, shift work, and managing interactions in high-stress situations.
Environmental: Possible exposure to chemicals, temperature/humidity extremes, infectious diseases, dust, fumes, gases, hazardous equipment, and loud noises.
ESSENTIAL FUNCTIONS
Adheres to current ACMA Case Management Standards of Practice and Scope of Services
Adheres to ANA Nursing Scope and Standards of Practice
Adheres to the ANA Code of Ethics for Nurses
Coordinates service-specific assessments, service planning, and enrollment
Works with all facets of the Case Management continuum (social support, referrals, discharge planning, SNF/Skilled Nursing placement, resource utilization)
Provides comprehensive, client-centered service planning and coordination
Collaborates with RN Case Managers/Social Workers for care coordination
Facilitates resource acquisition, referrals, and linkages
Provides ongoing case consultation with direct service providers
Develops and maintains internal and external resource relationships
Monitors services and updates client service plans to ensure continuity of care
Identifies patients through consultation and high-risk diagnoses (e.g., COPD, CHF, DM)
Assists with department reports, policy/procedure manuals, and program objectives
Assists with special projects and reports as assigned
Conducts system and procedural evaluations to measure progress and program compliance
Follows up on inpatient and outpatient referrals, provides case management coverage as needed, and ensures accurate clinical documentation
Improves the quality and completeness of clinical documentation
Coordinates with coding staff to assign DRGs reflecting patient status, and consults with physicians to finalize diagnoses
Conducts timely follow-up reviews to ensure documentation reflects care plans
Participates in monthly data review related to clinical quality, documentation, and insurance criteria
Performs UR coordination to ensure medical necessity in preadmission, admission, continued stay, cost containment, and discharge planning