The Referral Case Manager will be responsible for managing the referred cases specified by SMHWC practitioners from the beginning of the referral process to the final processing for payment, including prior authorizations of insurances if applicable.  The Referral Case Manager will attend and participate in meetings with both Medical and PRC to best standardize and communicate priority level determination procedures. In general, the Referral Case Manager will provide ongoing support and expertise through comprehensive assessment, planning, implementation and overall evaluation of individual patient needs. The Referral Case Manager will follow patients health prevention appointments such as mammograms, pap smear, PSAs, and colonoscopies. The overall goals of this position are: (1) enhance the quality of patient management and satisfaction, (2) promote continuity of care, and (3) insure cost benefit/effectiveness.  These goals will be achieved through integrating the functions of case management and utilization review of the discharge plan and follow up care.  The Referral Case Manager works under the direct supervision of the SMHWC Nursing Manager.

1. Assess, monitor, and evaluate referrals specified by the SMHWC medical practitioners.
2. Communicate with internal and external services and practitioners regarding patient care.
3. Improve collaboration and continuity of care.
4. Ensure patient education regarding pre-operative, post operative and necessity of care.
5. Confirm and document patient appointments were attended or rescheduled and determine how much follow up care is needed.
6. Coordinate “cases pending” scheduling of appointments with outside providers.
7. Ensure that patient tests are appropriate and necessary, carried out within the established timeframe, and results are promptly available.
8. Maintain and manage a list of patients who are recommended to have health prevention appointments such as mammograms, pap smear, PSAs, and colonoscopies, including calling patient to schedule appointment and work with PRC for payment of the appointment as needed.
9. Obtain health summary reports from outside providers, and track and file reports in an organized manner to aid in the referral process.
10. Obtain care and discharge plans from outside providers to review with inhouse practitioners in order to manage follow up care and maximize community resources.
11. Initiate and complete the pre-authorization process to ensure payment source.
12. Coordinate with internal/community departments and external agencies as needed to render services to all referred patients.
13. Coordinate with PRC, Medical Records, other departments as needed to ensure all needed records are sent to the referred provider.
14. Support the referral specialist as available.
15. Must maintain an acceptable departmental attendance record.
16. Must be reliable and prompt when reporting to work.
17. Required to attend job related, in-service, meetings, and training to maintain professional and technical knowledge.
18. Must adhere to tribal law and other applicable laws as well as tribal personnel policies and procedures.
19. May be required to satisfactorily complete an exam or other testing requirement(s) to determine skill proficiency.
20. The above duties and responsibilities are not an all inclusive list but rather a general representation of the duties and responsibilities associated with this position.  The duties and responsibilities will be subject to change based on organizational needs and/or deemed necessary by the supervisor.

1. RN is required. RN-BSN preferred.
2. Three or more years nursing experience required.
3. Excellent communication skills required
4. Six months experience with electronic health records system.   Required
5. Knowledge of SMHWC/IHS referral process is preferred.
6. Knowledge of Purchase Referred Care rules is preferred.
7. Experience with Intergy is preferred.
8. Knowledge of Medical Assistance/Medicare requirements for reimbursement is preferred/.
9. Experience with Microsoft Word and Excel or equivalent required.
10. Ability to communicate clearly and effectively with patients, providers and insurance companies required.
11. Understanding of medical procedures and patient/provider needs during all phases of treatment.
12. Excellent investigative and problem-solving skills.
13. Ability to deal effectively and respectfully with conflict
14. Excellent organizational skills with attention to detail
15. Possess background, experience and ability to communicate with physicians and earn trust.
16. High level of customer service skills.
17. Must be able to maintain confidentiality.
18. Must be capable of working with minimal supervision.
19. Must submit and pass a background security check to meet the Elder/Youth License Requirement as it pertains to the position and the location of the department prior to and during the course of employment with the Stockbridge-Munsee Community.
20. Must be willing to attend all applicable training.
21. Must pass pre-employment drug and health screening.  Must adhere to the Tribe’s Drug and Alcohol Free Workplace Policy during the course of employment.
22. Must be eligible for coverage under the employer’s liability insurance.
23. Must have demonstrated ability to maintain satisfactory working record in any prior or current employment.
24. Must be able to meet physical requirements of position.
25. Must abide by departmental and organizational safety, testing, and uniform guidelines.

1. This position requires a lot of sitting with occasionally stoop, kneel, crouch, and lift and/or move up to twenty-five (25) pounds.
2. Work environment requires excellent personal hygiene due to working in close proximity to others and in an enclosed area.
3. A Tuberculosis (TB) Screening and/or TB Skin Test may be required.