The Chronic Disease Case Manager will promote health care delivery across the continuum that will enhance the client’s quality of life, decrease fragmentation of care, while efficiently utilizing resources and containing cost. They will provide resource support to the Case Management Team. The Chronic Disease Case Manager will use a process that includes screening and case finding, comprehensive multidimensional assessment, care/discharge planning, connection with available resources, implementation of the plan, and on going monitoring and re-assessment. The plan sets goals and time frames for achieved goals that are appropriate to the individual and his/her family and are agreed upon by the family and the treatment team. This position reports directly to the Outpatient Services Program Manager.
PRINCIPAL DUTIES AND RESPONSIBILITIES
Works in coordination with the Outpatient Services Program Manager to develop, implement, and maintain the Case Management Program according to the program goals and objectives.
Identifies, develops and maintains a current resource database of federal, state, community, and institutional resources.
Attends team conferences and networks for relationship building and resource development.
Using the Nursing Process develops, implements, monitors and modifies a plan of care for and with the individual and family/caregiver consistent with cultural, social, and psychological requirements, through an interdisciplinary, collaborative team approach.
Understands the developmental needs of all ages of patients throughout the continuum of life. Is able to adjust care to those needs. Documentation reflects that understanding.
Monitors the clients’ progress toward goal achievement with periodic reassessments of changes in health status.
Provides tracking and follow-up of abnormal test results in collaboration with provider team concept.
Supports and participates in teaching and training to expand services and increase public awareness of chronic disease prevention and control.
Develops standards, policies, procedures, and protocols to support nursing case management practice.
Helps to maintain referrals to individual Specialty Clinics, including scheduling and assisting doctors with procedures during scheduled clinic hours.
Assists in the coordination of patient appointments in Anchorage and the implementation, maintenance and follow-up in coordination with MHC Providers.
Assures labs have been drawn as scheduled and assists in the coordination of medication reconciliation with the Primary Care Provider, the Specialty Clinic, and/or ANMC.
Establishes, participates in, and evaluates program improvement goals such as patient outcomes, cost savings, patient compliance, and return to productivity.
Coordinates and facilitates health promotion, illness and disability prevention, and health education activities.
Participates in daily huddles in outpatient with the appropriate team members to include Providers, nurses, and unlicensed support staff.
Provides appropriate communication with others on the team as the need arises.
Maintains professional ethical standards of conduct at all times.
Demonstrates a positive customer service attitude at all times.
Utilizes team building, problem solving skills, and lean principles, in the on-going quality improvement initiatives.
An Associate or Diploma in Nursing from an Accredited College. Current licensure as a Registered Nurse in the State of Alaska with at least two years Med/Surg experience and additional Case Management experience preferred. Must be able to pass the core competencies assigned to this position and maintain the educational requirements of the department. Ability to utilize various computer programs, including EHR/RPMS, Microsoft Office, and Excel database programs, iCare, CMET, AFHCAN, Vidyo, and Cerner. Demonstrates a wide theory base and sound clinical skills in order to interact in an effective manner with physicians, health team members, community agencies, and clients/families with diverse opinions, values, and religious and cultural ideals. Ability to work autonomously with little direction and be directly accountable for practice. Demonstrates leadership qualities including time management, verbal and written communication skills, problem solving, decision making, priority setting, work delegation, and work organization. Ability to lift up to 70 pounds and spend long periods of time standing or walking. Employee may be exposed to communicable diseases and hazardous materials.
Additional Salary Information: Sign On/Retention Bonus and Relocation Allowance
Maniilaq Association provides tribal, health and social services to residents of Northwest Alaska. A non-profit corporation, Maniilaq Association represents twelve federally recognized tribes located in Northwest Alaska. The Association manages social and health services for about 8,000 people within the Northwest Arctic Borough and the village of Point Hope. Maniilaq also coordinates tribal and t...raditional assistance programs, and environmental and subsistence protection services. With approximately 550 in its workforce, Maniilaq Association is also the largest employer