Through home visits and community events the PHN Case Manger instructs individuals and families in health education and disease prevention.  The PHN Case Manager is a member of the Public Health Programs Department Diabetes Team and serves as the lead Diabetes Case Manager among them.  The PHN Case Manager participates in all diabetes related activities and is supervised by the PHN Lead.


  1. Conducts home visits to appropriate enrolled IHC patients to determine patient needs and provides Public Health Nursing services.  Instructs family in care and rehabilitation of patient, and in the maintenance of health and prevention of disease for individuals, family members and the community.
  2. Develops, plans and implements a coordinated patient- centered care plan for individuals and families including the establishment of priority health needs and evaluation of care.  Instructs individuals, families and caregivers to recognize early signs of disease and deviations from normal health, and how to initiate appropriate action.
  3. Serves as the DM Team Lead Case Manager. Coordinates and consults with other DM Team members, IHC departments and outside agencies to plan care for individuals, families and caregivers.
  4. Attends appropriate internal and external partnership meetings on behalf of the Public Health Programs Department, as assigned.
  5. Participates in community health screenings by performing screening tests as authorized and interprets findings to individuals and/or families. Assists participants in identifying goals and activities that will lead to improved health outcome.
  6. As a Diabetes Team member participates in all aspects of the Diabetes program and other programs of the IHC Public Health Programs Department.  Activities include Continuous Quality Improvement (CQI), Diabetes Case Management, Intense Case Management, Interdepartmental Collaboratives, Infection Control Committee, other associated committees and staff meetings.
  7. Submits all patient documentation according to IHC Policies & Procedures within the appropriate timeframe. Utilizes and up-dates the PHP Patient listing on a monthly basis.
  8. Interprets social and physical factors in the environment that affect the patient’s care. Recognizes attitudes and cultural patterns related to health and researches culturally appropriate informational and educational materials, guides, and brochures.
  9. Provides guidance, support and supervision to the DM Team staff (Registered Dietitian, Physical Activity Specialist, Public Health Representative) in the implementation of care plan.
  10. Participates in educational activities including Quarterly IHC staff and PHP departmental meetings, mandatory IHC training, and continuing education.
  11. Assists in the design and implementation of field investigations and research projects as assigned.
  12. Participates in Peer Review both as a reviewer and reviewee.
  13. Ability to work in a fast-paced team environment.


Manages one or more subordinate employees. Acts in absence of Director of PHP when assigned.


To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.


Bachelor’s degree (BSN) in Nursing, with minimum of 1-year hospital experience and 1-3 years public health experience (including home visiting). Must be a certified Public Health Nurse. Applies Public Health Nursing intervention and concepts designed to prevent and control disease as required by local health regulations.


Must be a licensed California RN with PHN certificate. A valid California driver’s license and a good driving record will be required at the time of appointment and must be maintained throughout employment. Driving is required for this position. CPR certification must be acquired within six months of appointment.


Essential duties require potential employees to perform duties including but not limited to standing, sitting, walking short distances, lifting, reaching, repetitive hand movement – using and viewing a PC, calculator, landline telephone, cell phone, facsimile, copy machine and other general office supplies/ equipment and computer software.


  1. Responds promptly and with caring actions to patients and employees.  Acknowledges psychosocial, spiritual and cultural beliefs and honors these beliefs.
  2. Maintains professional working relationships with all levels of staff, patients and the public.
  3. Is part of a team and cooperates in accomplishing department/organizational goals and objectives.


Displays knowledge of normal signs of human development and ability to assess and provide age appropriate care. Contributes to the success of the organization by participating in quality improvement activities.


  1. Maintains current knowledge of policies and procedures as they relate to safe work practices.
  2. Follows all safety procedures and reports unsafe conditions.
  3. Uses appropriate body mechanics to ensure an injury free environment.
  4. Is familiar with location of nearest fire extinguisher and emergency exits.
  5. Follows all infection control procedures including blood-borne pathogen protocols.


  1. Maintains privacy of all patient, employee and volunteer information and accesses such information only on a need to know basis for business purposes.
  2. Complies with all regulations regarding corporate integrity and security obligations.
  3. Reports unethical, fraudulent or unlawful behavior or activity.
  4. Specifies privileges and responsibilities of employment, including compliance with an adverse incident reporting system.
  5. Maintains patient case files in accordance with all applicable laws and regulations and IHC policies.

Indian Preference shall be given in accordance with IHC’s Policies and Procedures Section 3, Part 3-1, Paragraph 5