RN Case Manager - Mental Health (44603)

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:

• 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.
• 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.
• 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.
• Develops and maintains internal patient care database for continuous tracking and follow up for continuity of care for active management of patients assigned.
• 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.
• Maintains compliance with applicable laws, such as patient confidentiality, abuse reporting, principles of consent and advanced medical directives.
• 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.
• Utilizes best practice model to identify, develop, and implement such practices for mental health case management.
• 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.
• 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.
• 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.
• Performs other duties as assigned by the supervisor consistent with the position and in compliance with WIHCC policies and procedures.