Medical - RN Case Manager - SDPI Program

The RN Case Manager for the Special Diabetes Program for Indians (SDPI) is responsible for delivering high-quality, culturally appropriate care coordination and health education for American Indian/Alaska Native patients affected by diabetes. This role focuses on clinical management, prevention strategies, and community outreach to improve health outcomes and reduce disparities. A key focus of this position is proactive outreach to individuals who are at risk for diabetes complications or not currently engaged in regular treatment.

 

 

Essential Duties and Responsibilities:

 

Primary Functions:

1. Conduct comprehensive nursing assessments for patients with diabetes, prediabetes, or related chronic conditions.

 

Primary Functions: continue

2. Develop, implement, and monitor individualized care plans to support disease management and reduce complications.
3. Deliver patient-centered diabetes education, medication reconciliation, lifestyle coaching, and self-management support.
4. Perform targeted outreach to patients who have missed appointments, are overdue for screenings, or have not been receiving regular diabetes care.
5. Use patient registries, EHR dashboards, and SDPI data tools to identify high-risk or disengaged individuals and initiate re-engagement strategies.
6. Collaborate with care teams to address barriers to care, such as transportation, housing instability, food insecurity, or lack of medication access.
7. Provide follow-up care coordination for abnormal A1c levels, missed labs, ED visits, or hospital discharges.
8. Coordinate referrals to primary care, behavioral health, podiatry, nutrition, or community support services as needed.
9. Participate in and support wellness events, group education classes, and traditional healing activities aligned with diabetes prevention.
10. Document all patient encounters, education, and interventions in the EHR and SDPI reporting systems accurately and timely.
11. Contribute to SDPI grant activities, including data collection, outcome tracking, reporting, and continuous quality improvement.
12. Engage with elders, and community partners to promote culturally safe, inclusive care.
13. Stay current on national diabetes guidelines, IHS resources, and SDPI best practices to inform program development and patient care.
14. Active involvement in the community to educate about risk factors for chronic disease, increase community-based screening methodologies, and recruit newly diagnosed individuals to SDAIHC for treatment and management. 
15. Assist with program evaluation, including performance measurement, member satisfaction surveys, and continuous quality improvement.
16. Adhere to organizational and departmental policies and procedures.
17. Perform the clinical and administrative duties necessary to meet the goals and objectives of the grant. 
18. Other duties as assigned.

 

Minimum Qualifications:

 

1. Education and/or Experience: Public Health Nursing Degree AND bachelor’s degree in nursing from a four-year college or university (RN).
2. Ability to view the patient as a whole person within the context of their family and community.
3. Excellent interpersonal and communication skills.
4. Computer and analytic skills to run reports and review data.
5. Current/non-restricted licensure in good standing in the State of California.
6. Minimum of 2 years of clinical nursing experience, preferably in community health, case management, or care coordinationMust be a team player and be willing to put the needs of the patients first.
7. Understand requirements for Patient Centered Medical Home.
8. Experience working with vulnerable populations (e.g., individuals with SMI/SUD, homelessness, complex medical needs)

 

Preferred:

 

1. FQHC background.
2. Familiarity with community health clinics and/or Indian Health Clinics.
3. ECW EHR.
4. Prefer a Master’s degree from an accredited university or professional school for a Nursing, and at least 2 years of experience; or a BA and 4 years’ experience

 

 

 

 

Special Conditions of Employment:

 

1. CPR/ BLS certification:Maintain a current Basic Life Support (BLS) certification issued by the American Heart Association (AHA), the American Red Cross, or an equivalent organization. Certification must include an in-person, hands-on skills assessment. Online-only certifications are not accepted.
2. Annual background checks: Consent to annual background checks as a condition of continued employment, to ensure compliance with organizational standards and eligibility requirements.
3. For-Cause Drug Screening: Comply with drug screening requirements when initiated by the organization for cause, to support a safe, compliant, and drug-free workplace.
4. Ongoing Compliance Requirements: Maintain up-to-date compliance with all required annual renewals, including professional licenses, certifications, physical examinations, TB testing, and mandatory regulatory trainings as assigned by the San Diego American Indian Health Center (SDAIHC).

 

 

Knowledge, Skills, and Abilities:

 

1. Excellent verbal and written communication skills.

1. Excellent interpersonal, negotiation, and conflict resolution skills.

Excellent organizational skills, record-keeping skills and attention to detail.

1. Excellent time management skills with a proven ability to meet deadlines.

1. Strong analytical and problem-solving skills.

1. Ability to prioritize tasks and to delegate them when appropriate.

Ability to act with integrity, professionalism, and confidentiality.Proficient with Microsoft Office Suite or related software. Proficiency with or the ability to quickly learn the organizations EMR and other billing software systems.

 

 

Physical and Mental Requirements:

 

1. Able to lift/move up to 20 pounds, move from place to place.
2. Able to stand, bend and reach for prolonged periods.  
3. Ability to do math, organize and prioritize workload, work effectively and efficiently under stress.
4. Ability to supervise, multitask, understand, and follow instructions.
5. Ability to proficiently read, write, speak, and understand English.

 

Customer Service:

 

1. Actively supports, promotes, and works to fulfill the Mission, Vision, and core values of SDAIHC.
2. Provides excellent internal and external customer service.  
3. Demonstrates SDAIHC’s Standards of Customer Service Behavior: Compassion, Attitude, Communication, Appearance, Sense of Ownership, and Teamwork.
4. Participates in on-going customer service training.
5. In every action, seeks to promote SDAIHC as a top service organization.

 

 

Quality Management:

 

1. Contribute to the success of the organization by participating in quality improvement activities.
2. Comply with all SDAIHC policies and procedures and proactively participates in the implementation of new initiatives.
3. Participate and ensures continuous quality improvement process as directed by clinic leadership.  

 

 

Safety:

 

1. Ensures regulatory compliance and adherence with policies and procedures related to safe work practices.
2. Participate in infection prevention through appropriate use of infection control measures during patient treatment and patient interactions.
3. Ensure compliance with regulatory requirements for maintaining physical spaces, equipment, and supplies.  
4. Uses all appropriate equipment and/or tools to ensure workplace safety. 
5. Immediately reports unsafe working conditions.  

 

 

Privacy/Compliance:

 

1. Maintains privacy and security of all patients, employee, and volunteer information and access to such information. Such information is accessed on a need-to-know basis for business purposes only. 
2. Complies with all regulations regarding corporate integrity and security obligations. Reports on unethical, fraudulent, or unlawful behavior or activity.
3. Upholds strict ethical standards.

 

 

Flexibility:Available for all shifts and, when required, able to work evenings and weekends

 

                       

Disclaimer

 

Nothing in this job description restricts management's right to assign or reassign duties and responsibilities to this job at any time. This description reflects management’s assignment of essential functions; it does not proscribe or restrict the tasks that may be assigned. This job description is subject to change at any time.

 

Acknowledgement

 

San Diego American Indian Health Center is an Equal Opportunity Employer. We encourage applications from all individuals regardless of race, religion, color, sex, pregnancy, national origin, sexual orientation, gender identity, gender expression, ancestry, age, marital status, physical or mental disability or any other protected class, political affiliation, or belief.

 

Preference is given to qualified American Indian/Alaskan Natives in accordance with the American Indian Preference Act (Title 25, U.S. Code Section 472, 473 and 473a). In other than the above, the San Diego American Indian Health Center, is an equal opportunity employer.

 

San Diego American Indian Health Center is an Equal Opportunity Employer. We encourage applications from all individuals regardless of race, religion, color, sex, pregnancy, national origin, sexual orientation, gender identity, gender expression, ancestry, age, marital status, physical or mental disability or any other protected class, political affiliation, or belief.