PROGRAM:            Fallon Tribal Health Center                                                      GRADE:      GS-17

SUPERVISOR:       Health Director                                                                               RANGE:      $26.04 – $31..09 (hourly)

FLSA STATUS:        Exempt     Non-Exempt     Public Safety       TYPE:       Regular Full-Time


This position connects patients to appropriate resources; assists patients with questions or concerns while navigating through the Tribal Health Center systems; and manages the coordination of care for patients who are most at risk for health deterioration, sentinel events, and/or poor outcomes and work holistically to ensure that care and treatment plans meet the physical, social, and emotional needs of patients.


  1. Monitor daily patients census and assignments to assure all patients are assessed for case management needs including coordination of care, follow-up treatment and care planning, consultations, referrals, advocacy and patient education.
  2. Connect patients to resources available throughout the Health Center and in the tribal/local community such as housing, social services, public assistance, and counseling services.
  3. Offers advocacy services to uninsured patients and their families to inform them of the availability and eligibility requirements of various health insurance coverage and/or programs.
  4. Meets ands assists patients in identifying case management services, individuals’ treatment and care plans following best practices, and coordinating related referrals and services.
  5. Assist with coordination with referral sources, family members, community agencies, and other care and treatment providers to provide the best treatment and case management options for patients.
  6. Provide a system to ensure patients, particularly elders or other vulnerable patients, are supported while seeking health care services at the Health Center or to referral sources. Coordinates care between the FTHC services to ensure their health and social needs are met, as well as continuity of care is maintained.
  7. Maintain effective communication with health care team members relating to assessment and planning needs and provider orders and help assist in locating resources for homecare, durable medical equipment, transportation, skilled nursing, facility placement, and outpatient follow-up.
  8. Work in conjunction with health center staff and other tribal/community partners to create and reinforce a patient focused culture within the Tribe. Work cooperatively with Health Center programs and services to ensure optimal patient access and satisfaction.
  9. Develops service plans which outline a specific plan of action with each patient needing case management services and makes referrals in accordance with plans to FTHC or external providers.
  10. Accurately completes in a timely manner all necessary forms, reports, patient case notes, case recordings and statistical reports.
  11. Provides information regarding Advance Directives, assists in filling out the forms, and obtaining appropriate witnesses, if necessary, to complete the documentation of Advance Directives.
  12. Documents complaints and concerns by listening to patient and patient family complaints; documenting details; determining what resolution is sought.
  13. Addresses complaints/issues by listening to patients and their families; directing them to appropriate supervisor or medical provider; helping them present facts to the health center management; developing acceptable resolutions; following-up on outcomes.
  14. Consults in the development of strategies to improve patient satisfaction; identifies best practice and opportunities for improvement and works collaboratively with leaders and staff; assists with staff education on improving patient satisfaction/experience opportunities.
  15. Complete all required and additional progress notes and uploading progress notes and accompanying documents to FTHC’s electronic health record (EHR) system in a timely manner.
  16. Performs other job-related duties as assigned by the supervisor.


  1. Required: Bachelor’s degree in Social Work, Counseling, Clinical Psychology, or related field and at least four (4) years related work experience, or Master’s Degree in Social Work (MSW)
  2. Requires Case Management Certification (ACM, CCM, or ANCC) within 36 months of hire.


(To perform this job, an individual must be able to perform each essential duty satisfactorily. Requirements, below, are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to individuals with disabilities to perform essential functions)

  • Knowledge of community resources; of case management principles, objectives, standards, and methods; and of program policies and procedures.
  • Knowledge of case management techniques in a primary care setting.
  • Skill in working and communicating with persons from diverse socioeconomic groups and capable of maintaining confidentiality, self-control and composure under adverse circumstances.
  • Ability to read, analyze, and interpret general health and social services guidelines.
  • Ability to effectively present information and respond to questions from groups or patients, center staff, and the general public.
  • Familiarity with federal, state & local resources available to meet the health/social needs of patients.
  • Ability to establish and maintain effective working relationships with patients, health center staff, tribal employees and the public.
  • Ability to deal with difficult people and work in stressful situations.


  1. This position is covered by the provisions of the Indian Child Protection and Family Violence Prevention Act (Public Law 101-630), as amended, which requires an investigation of the character of each individual who is employed, or is being considered for employment, in a position with duties and responsibilities that involve regular contact with or control over Indian children. A criminal history investigation will be performed, and the applicant must meet the requirements of the Act.
  2. The duties of this position include mandatory reporting pursuant to 1) the Victims of Child Abuse law (34 USC § 20341) and 2) elder and vulnerable person laws (NRS 200.5093), as incorporated by decision of the FBC that elders and those who cannot speak for themselves are entitled to the same protections. Because such laws may subject employees to criminal penalties under FPST LOC § 5-50-040 and/or 18 U.S.C. §§ 1169 and 2258, all employees hired to this position must complete a Mandatory Reporter training within 90 days of hire.

Work Environment

This position is functioning within a healthcare environment.  The incumbent is responsible for adherence to all health center and department specific safety requirements.  This includes but is not limited to the following: complying with personal protective equipment requirements, hand washing and sanitizing practices, complying with department specific engineering and work practice controls and any other work area safety precautions as specified by FTHC/Tribal policies and procedures.


Fallon Paiute-Shoshone Tribe and Native American/Indian Preference:  Employment preferences to members of the Fallon Paiute-Shoshone and to members of federally-recognized Indian Tribes shall apply to this position pursuant to the Tribe’s Personnel Policies.  Persons of Tribe and/or Indian ancestry and wish to claim these employment preferences should submit a copy of the Tribal Enrollment Card/Certification indicating the name of the Tribe they are enrolled with.

U.S. Veteran’s Preference:  Preference to opportunities to veterans honorably discharged from the United States Armed Forces shall apply to this position pursuant to the Tribe’s Personnel Policies.

Equal Opportunity Employer:  The Fallon Paiute-Shoshone Tribe does not discriminate on the basis of race, color, national original, sex, religious preference, age, handicap, marital status, political preference, genetics or membership or non-membership in any employee organization, except as allowed by Federal and/or Tribal Law.

Drug Free Workplace:  The Fallon Paiute-Shoshone Tribe is a drug-free workplace.  All employees are subject to a pre-employment and random drug screens.

Driving Record:  Employees who drive tribal vehicles must have a valid Nevada Driver’s License, be insurable under the Tribe’s vehicle insurance program, and must also provide a DMV printout annually.

Background Checks:  All employees must be able to pass a background check per the Tribe’s Background Check Policy.

Position Description Limitations:  This position description does not constitute an employment agreement between the Tribe and the employee, and is subject to change by the Council as the needs of the Tribe and the requirements of the job change.  This position description is not intended to present a descriptive list of the range of duties performed by any employee in this position and is not intended to reflect all duties performed within the position.

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