Name Care Coordinator



PO BOX 278

PABLO MT  59855

(406) 675-2700

PERSONNEL OFFICE FAX:  (406) 675-2711




****V A C A N C Y   A N N O U N C E M E N T****


TITLE:                    Care Coordinator


LOCATION:            Tribal Health Department

                             St. Ignatius


SALARY:                Exempt - Salary Negotiable


CLOSING DATE:     Open Until Filled



The successful applicant, if not already employed by the Tribes must pass a pre-hire drug test, serve a mandatory six (6) month probationary period and pass a background check.  The Care Coordinator is a member of a patient-centered medical home care team with both medical provider staff and other health care staff (clinical and non-clinical). The patient-centered medical home is a team-based health care delivery model whereby patient treatment is coordinated through the patient’s primary care provider to ensure they receive the necessary care when and where they need it, in a manner they can understand (American College of Physicians, 2017). The Care Coordinator ensures Tribal Health recipients receive quality patient-centered care that is consistent with the patient-centered medical home principles, and that is timely, appropriate, cost effective, sensitive and coordinated to achieve desired clinical outcomes.

  Duties of the position include, but are not necessarily limited to the following:

  • Serves as the point of contact, advocate, and informational resource for patients, care team, family/caregiver(s), and community resources
  • Develops a plan of care in coordination with the patient, primary care provider, and family/caregiver(s) utilizing clinical quality indicators for all patients on case load, including but not limited to patients diagnosed with cancer, hypertension, diabetes, comorbidities, etc
  • Regularly evaluates plans of care with patients, providers, and care team as needed, develops mutually agreed upon goals, and provide patient/family education and behavior change coaching
  • Provides case management, care coordination, and patient education to ensure continuous and comprehensive care for patients on case load
  • Works collaboratively with the health care team including the clinicians, pharmacists, behavioral health specialist, other nursing staff and medical assistants
  • Develops plan of care for hospital transitions in order to identify factors to decrease the likelihood of readmission
  • Ensures case management is implemented and managed to improve continuity and quality of care
  • Assists with obtaining lab results, medical tests, visit summaries and other information from outside facilities and assists with arranging appointments, procedures, and discharge planning
  • Increases continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals 
  • Maintains communication with patients on case load concerning treatment progress and diagnostic reports
  • Engages patients to take an active role in maintaining and/or improving their physical and mental health
  • Identifies and coordinates referrals to outside facilities and resources in regards to patient need 
  • Completes documentation of all patient encounters and care coordination activities in the electronic health record promptly and appropriately. 
  • Is responsible for the management of nursing division personnel at assigned duty station which includes scheduling, assigning and delegating tasks, performance evaluation, training, assessing competency, and counseling
  • Attends internal and community meetings as assigned and participates in Quality Improvement activities. 
  • Participates in community activities designed to promote Tribal Health and community health and education with approval supervisor and Tribal Health Administration.
  • Assists with the triage of patients, including triaging telephone calls and walk-in patients.
  • Recognizes urgent/emergent patient and clinic situations and initiates emergency medical procedures according to scope
  • Partners with the Salish Kootenai College School of Nursing as a preceptor for ASN and BSN nursing students
  • Conducts 1:1, or group education classes as needed.
  • Is an active participant on the Tribal Health Case Management Committee
  • The Care Coordinator will perform job duties of Clinic Registered Nurses/Medical Assistants as needed to include:
    • Check patients into clinic, taking health histories and vital signs
    • Elicit medical information and perform nursing assessments on each patient
    • Triage patients presenting to the clinic as well as patients who telephone
    • Perform the following nursing procedures
      • obtain heights, weights, other body measurements and vital signs
      • obtain blood draws, specimen processing, finger stick for appropriate testing
      • obtain specimens (urine & other various) for culture and testing, including pregnancy testing
      • prepare specimens for shipment when indicated
      • give injections including child & adult immunizations, medication administration, etc, per medical provider order   
      • start intravenous lines and administer medications as ordered by medical  provider
      • clean and dress wounds
      • assist medical providers with procedures
      • perform EKGs as ordered by medical provider
    • Call or fax prescription to pharmacies as ordered by medical provider when appropriate.
    • Maintain inventory of clinic supplies, placing orders as necessary while staying within budgetary limitations.
    • Clean and sterilize equipment, coordinate maintenance/repair of clinic equipment with Practice Manager per quality assurance standards.
  • Other duties or special projects as assigned.


  • Post-secondary education in mental health related field or 2 years related experience and/or training; or equivalent combination of education and Experience in grant funded activities including fulfilling objectives and completing progress reports and financial reports. 
  • Current, unrestricted Registered Nurse license from the State of Montana or other state.
  • Graduate from an accredited Bachelor of Science in Nursing (BSN) program, with two years of nursing experience, with at least one (1) year of ambulatory care nursing experience preferred. OR
  • Currently enrolled in a BSN program. Five (5) years of nursing experience, with at least one (1) year of ambulatory care nursing experience preferred.
  • Basic Life Support certification. Advanced Cardiac Life Support preferred.
  • Certification in Care Coordination preferred, required within three (3) years of employment.
  • Must maintain proper licensure/certification and registration; if required.
  • Must possess a valid driver’s license.


  • Request position description for a detailed description of desirable qualifications.


  1. Completed Tribal employment application.
  2. Copy of relevant academic transcript.
  3. Completed supplemental background questionnaire-contact the Personnel Office.
  4. Proof of enrollment from a federally recognized Tribe if other than CSKT.
  5. If claiming veteran’s preference, a copy of DD214 must be submitted.


SUBMIT ALL OF THE ABOVE TO: Tyshina Whitworth, Personnel Office, PO Box 278, Pablo MT 59855, Telephone (406) 675-2700 Ext. #1043.

FOR MORE INFORMATION:  Shonda Bolen, Tribal Health Department – (406) 675-2700 Ext. #5032   

File name Care Coordinator 2.26.18.pdf
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Owner Evelyn Charlo
Date added 02/26/2018 09:04 AM
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