Case Manager

Incumbent will provide case management services to high risk patients and will serve as a health advocate for patients.


Health and Wellness Department

Pay Grade:




Job Description:

This position is located in San Felipe Pueblo between Albuquerque and Santa Fe serving a community of approximately 3500.  Incumbent will serve the community through work with other tribal programs/activities, home visits. This is a community based position. The incumbent will provide case management services to high risk patients and will serve as a health advocate for patients and their families. This is a professional position that will require the incumbent to use appropriate clinical skills and knowledge of the health care systems in the community and surrounding areas to assure access to care, to evaluate standards of care being rendered, to teach and counsel users on the care system, and to participate in quality improvements activities. Additionally, the incumbent will help to develop and implement a care coordination and case management system for San Felipe Pueblo.


  • Assist in development and implementation of annual community assessment, monthly work plan, quarterly program report and annual report, in accordance with Pueblo of San Felipe Tribal Administration and the Indian Health Service P.L.93-638 contract and grant funding requirements.
  • Work closely with all members involved in the Pueblo of San Felipe Health & Wellness Department, Pueblo of San Felipe Tribal Administration, Indian Health Service and other state and federal agencies in the development of an integrated case management program that responds to the health care needs of Pueblo of San Felipe and their families.
  • Manage referrals for patients to outside providers, IHS clinic, Health and Wellness Department programs and other Tribal program.
  • Maintains documentation of activities and tracks health status indicators that may be needed for reporting and quality assurance.
  • Develop, implement and maintain a system to coordinate referrals to services provided outside the local health system, including services provided at IHS facilities and other non-clinic based Health and Wellness Department programs.
  • Track the funding sources for each referral and track the liabilities that will be covered by the IHS Contract Health funds.
  • Serve as a health advocate for patients and family members who need assistance in accessing needed health care services from other health care professionals, community organizations and schools, Indian Health Service and other State, County, Federal agencies, care providers, and health plans.  Is available to meet with clients and family members and directly assists them as needed to secure the services they need.
  • Coordinate patient care and home visits with Community Health Representatives, behavioral Services, and Community Health and Wellness nurse.
  • Participate in the interdisciplinary case management team meetings and define policies and procedures that assure a comprehensive health care system which promotes optimal levels of health and wellbeing for patients.
  • Provide health information, statistical information, and reports to the Clinical Services Director and Director of Health and Wellness on a regular basis as requested. Track health status indicators and other information that may be needed to assure health improvement issues are identified early and prevention strategies are implemented.
  • Works closely with the Patient Benefits Coordinator to ensure eligible Pueblo of San Felipe residents have access to all health benefits for which they are entitled. Identify any barriers to accessing and maintaining benefits. 
  • Teach and supervise patients and families in techniques of positive health measures.
  • Provide oversight and education for ancillary health care staff as appropriate to assure quality health care is being rendered.
  • Assist in developing new community health programs and updating or revising current program policies and procedures as indicated by program evaluation or demographic changes.
  • Participate in the development of Health & Wellness Department goals and objectives in coordination with Tribal Community Health Programs,
  • Maintain a high level of compliance with legal and ethical aspects of case management. 
  • Conducts community analysis in partnership with community representatives and in collaboration with other public health or health care professionals.
  • Participates in continuous evaluation of program and services and performance improvement.

Additional Resposibilities:

  • Undertakes a comprehensive and accurate documentation and assessment.
  • Demonstrates computer skills necessary to organize data for essential care delivery.


  • Education:  Nursing degree, Social work, or Case Management Certification(CCM)or graduate level nursing education
  • Experience/Basic Knowledge:  1 year experience in Case Management .Verbal Communication, Health Promotion and Maintenance, Listening, Quality Management, Energy Level, Integrity, Informing Others, medical terminology, Medical Teamwork, Multi-tasking Ability to work in a culturally diverse setting is required. Familiarity with medical Case Management models is highly desirable.  Experience with conducting community needs assessments related to health care and medical conditions is appreciated.
  • Required Licenses/Certifications: Current license or certification required for position by the State of New Mexico, CPR certification, and valid New Mexico Driver license. Case management Certification (CCM).
  • Physical Requirements: Must have manual dexterity to enter and retrieve data from a computer. Ability to sit and stand for long periods. Bends and stoops regularly.
  • Preferences: San Felipe Preference, NA/AI and Veteran’s Preference. Keres speaking preferred, or ability to work effectively with a translator.

Working Conditions:

Works in office and within the community. May be seated for long periods of time. As Essential Staff, Some weekends and after hours.

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