Job Title: PRC RN Case Manager

Job Code: PRCRNCM

Department: PRC

Division: Finance

Salary Level: Exempt 4

Reports to: PRC Manager

Last Revised: March 2025

Primary Function

The PRC Case Manager is responsible for the collaborative process that assesses plans, implements, coordinates, monitors and evaluates the referral options for CIHA patients and evaluates the services required to meet the individual’s needs, using communications and available resources to promote quality, cost effective outcomes.

Job Description

• Utilizes best practice models to identify, incorporate or develop best practices for Outside referrals. Collaborates with other teams to share and establish best practice for health promotion and disease prevention strategies.
• Manages referrals by addressing and resolving patient’s referral needs through a team based approach.
• Incumbent will be responsible for reviewing and managing complicated or complex clinical issues involving referrals to the PRC department.
• Utilizes iCare to track, monitor, and assure the appropriate follow-up of clients.
• Utilizes NC Health connects for information gathering and data collections for management of care needs or gaps in care
• Coordinates and follows up on referrals to outside specialty providers. Emphasis is placed on follow up with the primary care teams to ensure treatment notes are available timely.
• Manages complicated/complex discharges requiring PRC funding.
• Gives clinical guidance for referrals in PRC and other non-clinical departments.
• Is a member and regularly attends Managed Care Team meetings weekly and as needed.
• Reviews and prioritizes referrals daily utilizing sound clinical judgment.
• Creates and maintains CHEF cases and reports routinely.
• Follows up with providers and care managers to ensure outstanding referral issues are addressed and resolved in a timely manner.

• Negotiating, procuring and coordinating services and resources.
• Case managers are responsible for providing the most cost effective care that is safe and results in the best outcome for the patient
• Coordinates care with local, tribal, community, and state services to support the patient health care needs
• Utilizes critical thinking skills such as screening, assessing, planning, implementing, follow up, transition and evaluating while considering the PRC rules and regulations
  

PRC Referral Management Tasks Licensure, Certification, and Experience Job Knowledge

• Identify patient needs, current services and available resources, connecting the patient to services /resources to meet medical requirement
• Serve as an advocate for the patient: Document case management and medical treatments to include any necessary referrals/ patient appointments; keep active communication with the outpatient, inpatient and emergency department nurse case managers, enhancing patient care.
• Ensure contracted vendors utilize Medicare Like Rates (MLR) for reimbursement; educate both patient and vendor on referral purpose and visits authorized
• Reviews Medical record from outside referrals for recommendations and follow up care.
• If an outside provider requests additional referrals- a new referral must be written by the primary health care team (physician &/or case manager) before funds can be allocated.
• Generates reports from the Referred Care Information System (RCIS) or the Electronic Health Record (EHR) as needed.
• Work directly with all members of case management on communication between PRC and Case Management members.
• Ensuring that the PRC process works seamlessly with the communication of every member of the Care team and outside departments
• The incumbent will be evaluated annually on his/her ability to identify, assess, analyze, and evaluate data and solve problems through the CIH Performance Appraisal System.
• Performs ongoing assessment by actively participating in the determination of meeting the nursing care needs based upon collection and interpretation of data relevant to the health status of the client.
• Collects data from relevant sources (patient, family, or caregiver) regarding the biological, psychological, social and cultural factors that might influence and impact the health status of the individual and utilizes this data in patient center care plan development.
• Collects data through observations of appearance and behavior, measurements of physical structure and physiological function, and other information in an effort to place consultations and/or referrals to the correct internal and external resources.
• Provides clinical guidance, leadership, and training to PRC personnel.
• Coordinates health care needs through referrals to support services, community, and tribal resources to promote continuity of care.
• Participates in the development and implementation of performance improvement activities. Identifies and reports risk management issues.
• Promotes patient advocacy and confidentiality.
• Serves on Committees as appointed.
• Maintains and promotes positive and constructive communications and activities within PRC, other departments, tribal, and community agencies for purposes of coordinating and understanding of goals and objectives relevant to the population served.
• Functions appropriately during disasters.
• Updates and maintains currency/competency in nursing practices and standards by attending training and in-services.
• Bachelor or Associate Degree in nursing from an accredited program required. Minimum of two years of nursing experience preferred
• Applicant must have an unrestricted valid Registered Nurse license within the state of North Carolina or a state that is accepted as reciprocity.
• Current Basic Life Support (BLS) minimally required. Can be acquired through the facility within 6 months following appointment to position.
• Applicant must have a valid North Carolina driver’s license.
• Certified Case Manager (CCM) certification or equivalent experience a plus.
• Knowledge of principles, practices, techniques, and theories of professional nursing.
• Knowledge of the nursing process and its application to clinical practice.
• Knowledge of the biological aspects of the disease process and illness in order to recognize complications and therapeutic interventions required.
• Knowledge of medications and dosages in order to recognize desired effects, side effects, and complications of their use.
• Knowledge and ability to analyze the results of various medical procedures and translate into appropriate nursing interventions.
• Knowledge and ability to independently plan, manage, and organize work in order to meet priorities, accomplish work within established time frames and work in stressful situations.
• Knowledge of the occupational functions of multi-disciplinary health care team.
• Knowledge of the culture and medical health profile of the patient population.
• Knowledge and ability to teach and counsel patient/family on health maintenance and disease prevention.
• Knowledge of available health care programs and community resources.
• Knowledge of processes and procedures for establishing, revising, continually monitoring, and evaluating standards for the practice of nursing.
• Knowledge of problem oriented medical record methods.
• Knowledge of legal and ethical aspects of nursing.
  
  

Complexity of Duties

Guidelines consist of professional standards of practice as determined by the nurse practice act, nursing and medical policy and procedures, standing orders, and hospital and agency policies. Complies also with federal, state, accrediting and local regulations. These guidelines are not always specifically applicable to the individual patient or situation and independent judgment is required in selecting the most appropriate guideline, and applying the intent of the guideline to the specific situation at hand. The nurse receives assistance from the PRC Manager with difficult or unusual problems.

Supervision Received

PRC Case Manager is under the supervision of the PRC Manager. The work is evaluated for technical soundness and adherence to professional standards.

Responsibility for Accuracy

The incumbent has a positive effect upon the recovery of the patient and is responsible for following policies and procedures, which serve as hospital guidelines and prevents errors from occurring. Errors can have a negative patient outcome since the incumbent’s performance affects the health, recovery, and rehabilitation of patients, and the quality of care provided. Evaluations and observations are used to modify and develop clinically appropriate treatment plans. Work can be verified or checked by the immediate supervisor, other health care providers or systems checks, but usually the responsibility for accuracy relies solely on the incumbent.

Contacts With Others

Contacts are with patients, families, hospital personnel, and community agencies. Contacts with patients, families, and hospital personnel are to exchange, provide, and obtain information concerning the patient’s physical and psychosocial health care problems, and needs. The nurse uses teaching and counseling methods to influence and motivate patient and family behavior. Contacts with other health care or related disciplines within the hospital are for the purpose of collaboration and consultation. Tact, courtesy, and professional conduct are required to maintain positive working relationships. Utmost sensitivity and confidentiality is required when dealing with patients and families.

Confidential Data

The incumbent has access to highly confidential patient medical and personal information. The Privacy Act of 1974 mandates that the incumbent shall maintain complete confidentiality of all administrative, medical, and all other pertinent information that comes to his/her attention or knowledge. The Act carries both civil and criminal penalties for unlawful disclosure of records. Violations of such confidentiality shall be cause for adverse action.

Mental/ Visual/ Physical

The level of concentration varies with tasks, with close attention to detail required while entering data and verifying accuracy of information. Duties of this position require the employee to be mobile, reach with hands and arms, speak and hear. Must have visual acuity. Position is subject to frequent interruptions, requiring varied responses. Must be able to handle multiple projects simultaneously, work independently and meet deadlines and time frames. May occasionally move more than 15 pounds.

Environment

Majority of work is performed within a hospital environment requiring interaction throughout the hospital. Occasional travel is required. Immunizations are required of all employees.

Customer Service

Consistently demonstrates superior customer service skills to patients/customers by demonstrating characteristics that align with CIHA’s guiding principles and core values. Ensure excellent customer service is provided to all patients/customers by seeking out opportunities to be of service.