Nurse (Case Manager)

Department of Health and Human Services

This position is located at the Phoenix Indian Medical Center in Phoenix, AZ. Several vacancies across multiple specialized functional areas, Outpatient Clinical Care Coordination, Outpatient Case Management, Specialized Case Management (Diabetes & HIV). Incumbents provide advanced professional nursing care coordination, longitudinal case management services.

• Total Compensation Package - Check out IHS's outstanding total compensation package for this job: Registered Nurse Total Compensation | Pay (ihs.gov) Outpatient Nurse Clinical Care Coordinator Duties: Provides real-time clinical care coordination and nursing triage for patients with complex healthcare needs, determining appropriate disposition and escalating acute changes in condition to providers. Coordinates referrals, authorizations, specialty care, and follow-up services across healthcare settings to promote timely access and continuity of care. Coordinates transitions of care following hospitalization, including medication reconciliation, follow-up appointments, and resolution of barriers to the plan of care. Uses clinical data, registries, and patient care gaps to support panel management, targeted outreach, and clinic-level quality improvement activities. Outpatient Nurse Case Management Duties: Independently manages an assigned caseload of patients with chronic, recurring, complex, or multi-system health conditions requiring longitudinal case management. Conducts comprehensive nursing assessments and develops, implements, evaluates, and modifies individualized care plans based on clinical, psychosocial, cultural, and resource needs. Coordinates services and transitions of care across providers, healthcare facilities, tribal programs, and community resources to address complex barriers and promote continuity of care. Serves as a clinical resource on complex case management issues and uses patient outcomes and program data to recommend improvements to case management practices, policies, and procedures. Diabetes Case Management Duties: Provides comprehensive case management for patients with diabetes, including screening, assessment, care planning, implementation, monitoring, and reassessment. Develops individualized care and service plans with patients, families, and the interdisciplinary healthcare team based on identified needs and available resources. Coordinates healthcare services across PIMC, other service units, contract providers, tribal programs, and community resources to promote continuity of care. Monitors patient progress and outcomes, revises care plans as needed, and provides patient education and advocacy to promote self-management and effective use of healthcare resources. HIV Case Management Duties: Provides comprehensive HIV case management across inpatient, outpatient, contract, and community settings to promote continuity of care from pre-admission through post-discharge. Conducts comprehensive assessments and develops individualized care and service plans in collaboration with patients, families, interdisciplinary teams, and community providers. Monitors and reassesses patient needs, treatment plans, services, and outcomes and coordinates ongoing healthcare and community resources. Provides patient advocacy and specialized HIV case management support related to treatment adherence, prevention, outreach, counseling, and continuity of care. This is a competitive vacancy announcement advertised under Direct Hire Authority. Selections made under this vacancy announcement will be processed as new appointments to the civil service. Current civil service employees would therefore be given new appointments to the civil service; however, benefits, time served, and all other Federal entitlements would remain the same. IHS Selectees whose duties and responsibilities require them to work permanently, temporarily, or occasionally in an IHS healthcare facility must comply with the IHS Employee Immunization Policy related to vaccine-preventable diseases, consistent with recommendations for healthcare workers. Vaccine exemption requests may be available, as outlined in the IHS Employee Immunization Policy and facility guidance.

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