Nurse (Clinical/Case Management)

Duties

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Conduct comprehensive assessments of beneficiaries with complex medical, psychosocial, and resource needs; develop patient-centered, cost-effective plans of care with patients, families, providers, payers, and community resources.

Coordinate healthcare services, referrals, appointments, specialty care, and ancillary support across military treatment facility (MTF), civilian, and community systems to achieve timely, appropriate care and positive outcomes.

Serve as the primary patient advocate and liaison between patients, families, healthcare professionals, and external providers; identify and mitigate barriers to healthcare access, utilization, and adherence.

Monitor and document patient status, care-plan progress, interventions, and variances in the electronic health record; intervene when patients deviate from the expected progression of care.

Collaborate with interdisciplinary teams to evaluate complex or unusual clinical and administrative issues, analyze incomplete or conflicting information, and recommend feasible alternatives that address serious medical concerns.

Screen, interview, counsel, and enroll appropriate case-management clients; participate in daily multidisciplinary meetings and review available data sources to identify patients who may benefit from case-management services.