Position: Case Manager-Diabetes

Program:  Wind River Family and Community Health Care

Salary:  D.O.E 

Opening Date:  January 9, 2020

Closing Date:  January 24, 2020

Hours: Monday-Friday 8:00am-4:45pm


The Diabetes Case Manager will provide the following essential features of Case Management:

  • Identify Diabetic and/or prediabetic patients in need or at risk. 
  • Assessment of needs 
  • Development of individualized care plans 
  • Implementation of the care plan
  • Monitor outcomes 
  • Re-assessment throughout the process

Improved measures for ABC’s

  • A1C
  • Blood pressure
  • Cholesterol (lipids)
  • Kidney function (Creatinine) 

Interventions/approaches may include:

  • Self-management education/support
  • Home visits
  • Telephone calls
  • Patient reminders
  • Utilization of Multidisciplinary resources
  • Utilization of newer technologies 
  • Telemedicine

Case Management effectiveness will be measured by the following indicators:

  • Increased delivery of clinical services which contributes to improvement in blood sugar control. 
  •  Improved self-monitoring, patient education, laboratory testing, eye, foot and dental exams. 
  •  Referrals to Nutritionist, Diabetes Nurse educator for patient education/consultation.  Referrals to behavioral health if indicated.

Job Duties: 

  • Completion of assessments/self-care checklists, summary reports, data entry and creation of case plans. 
  • Peer specialist services, ancillary support services to groups and individuals and implementation of evidenced-based and culturally best practice services.
  • Assist in organizing services and supports as an integrated system of health care for patients.
  • Establish and maintain quality relationships with agencies, community and other resources to facilitate appropriate referral recommendations.
  • Document all contacts and services in narrative form, enter data into the appropriate database, and obtain all required signatures for service delivery.
  • Assist patients in accessing supports and services as specified on individual plans of care
  • Assist in facilitating education groups.
  • Provide input and recommendations for treatment planning.
  • Work to resolve conflicts at the team level and effectively use supervision and management for further conflict resolution.
  • Attend all mandatory training and staff meetings.
  • Adhere to all WRFCHCS policies and procedures and employment policies.
  • Performs all other duties assigned

The day to day workload will be conducted Monday through Friday, from 8 a.m. to 5 p.m. However, evening and weekend hours may be required. The CM shall demonstrate the highest standard of personal integrity, honesty, confidentiality, and truthfulness in all professional and personal dealings. The CM shall promptly report any conflict of interest to their supervisor concerning anyone coming before them for care. 

Knowledge Required by the Position:

Bachelor’s in social work, or Registered Nurse, or Certified Nursing Assistant with five years of related experience in case management or direct care plan services delivery to adults in the field. Training will be required and provided to obtain certification as a social worker and/or community health worker as a part of acceptance of a Case Manager.

The applicant must have two (2) years of continuous recovery from addictive substance use and behaviors, must have a valid driver’s license, must complete a comprehensive background investigation. 

Communication skills are required to effectively coordinate services between WRFCHCS and entities serving the Wind River Reservation. The ability and skill to compile and write reports from various documents maintained within WRFCHCS is essential.

The applicant must have the ability to work under stressful situations and must be highly motivated to ensure that the highest possible quality of care is made available to individuals referred for services.

Supervisory Controls:

The CM is part of the Case Management Team under the direct supervision of the Case Management Department Head. The supervisor sets all standards of work performance, develops deadlines and benchmarks for the work that needs to be completed.  The supervisor will directly supervise the delivery of services by the CM and shall sign all care plans and orders related to the delivery of services to individuals served. The CM will perform the general and specific job duties of the position, maintains strict confidentiality of all client/patient information including all requirements of the Patient Protection and Accountability Act and Health Information Patient Protection Act, and established policies. The supervisor is kept informed of progress and potential issues.  The work is reviewed in terms of effectiveness in meeting expected results.


Guidelines include WRFCHCS policies, procedures, and manuals, as well as federal, state and tribal regulations, 

Factor 4 – Complexity:

The work requires knowledge of principles & practices in diabetes case management, social work and integrated systems approaches to health care delivery. Knowledge of the People of the Wind River Indian Reservation, tribal government structure and systems, including its health, and welfare is required. Must have knowledge of services for diabetes, prediabetes, nutrition and weight management. Must have the necessary knowledge and education to gain a thorough understanding of the existing patient population that WRFCHCS serves.  Requires the ability and business knowledge to develop calendars, schedules, data collection reports, and informational/educational materials. Familiarity with or willingness to learn motivational interviewing techniques, various diabetes educational modalities and assessment instruments. General phone skills, office equipment, word processing and computer skills are required including use of Electronic Health Record, Microsoft Office Suite Programs and Google Documents.

Personal Attributes:

The incumbent must maintain strict confidentiality and high ethical standards in performing the position.  The incumbent needs to be respectful, possess cultural awareness and sensitivity, be flexible, and demonstrate sound work ethics.

How to Apply:

Complete a Northern Arapaho Tribal application form and submit it to the Northern Arapaho Human Resources program.  Applications can also be hand delivered to Northern Arapaho Human Resources at the Tribal Complex Building, located at 533 Ethete Road, Ethete, WY., or to the WRFCHC HR Department, at 120 North 6th Street East, Riverton, WY.  Indian preference applies.

Application forms and the full job description can be obtained on the Tribe’s website at www.northernarapaho.com, or at www.windrivercares.com 

For more information please call 307-856-9281 Ext. 134

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