Registered Nurse - Case Manager

Case Management Position

This case management position is with the active duty and family health clinics. The patient load is challenging and requires a person who has an extensive work history of case managing patients in person in a clinic setting. The CM will work with many providers and in-house and community agencies and will coordinate resources and care world-wide. Familiarity with the military is a plus in understanding the needs of active duty patients. This case manager will also cover pediatric and internal medicine patients when needed.

Responsibilities

Attends and participates in meetings during normal duty hours, professional staff inservices, and other appropriate professional activities such as, but not limited to the following: Population Health Function (PHF) meeting, Medical Management (MM) staff meetings, and others required by applicable regulations, MTF guidance, or as directed by the Director of Medical Management or his/her designated representative. Coordinates and participates in interdisciplinary team meetings, designated facility meetings, and Care Coordination meetings. Shares knowledge and experiences gained from own clinical nursing practice and education relevant to nursing and case management.

Participates in the orientation and training of other staff. May serve on committees, work groups, and task forces at the facility. Completes orientation and competency verification programs in accordance with (IAW) unit guidelines. Completes all required electronic medical record training, MTF-specific orientation and training programs, and AF/DoD mandated Case Management training. Follows applicable local MTF/AF/DoD instructions, policies and guidelines.

Ensures a safe work environment, employee safe work habits and patient safety IAW regulatory agencies, infection control policies, and process improvement initiatives.HCWs shall be in the work area and available for work at the appointed times. Completes all in-processing and out-processing within MTF requirements (e.g., badges, e-mail accounts, Privacy Act, etc.).

All patient charting is included as part of the patient visit and must be completed within the duty day. Completes medical record documentation and coding, and designated tracking logs and data reporting as required by local MTF/AF/DoD instructions, policies and guidance. Conducts standardized peer review or gap analysis as directed by DHA/AF guidance, under the Chief Nurse's approval.

Must maintain a level of productivity and quality, with minimal supervisory direction, consistent with: complexity of the assignment; facility policies and guidelines; established principles, ethics and standards of practice of professional nursing; the Case Management Society of America (CMSA); American Accreditation Healthcare Commission/Utilization Review Accreditation Commission (URAC); The Joint Commission (JC); and other applicable DoD and Service specific guidance and policies. Must also comply with the Equal Employment Opportunity (EEO) Program, infection control and safety policies and procedures. Must participate in periodic peer reviews per AF guidelines.

Assessment: Proactively identifies and evaluates patients and families for case management activities from a variety of sources such as discharge/disposition planning, referrals, the Medical Evaluation Board (MEB) process, the healthcare system, employers and facility staff. Conducts systematic, on-going, thorough collection of patient's physical, emotional, psychological, social and medical status and information via direct patient communication and other relevant sources such as professional and nonprofessional caregivers, medical records, and family/caregiver interviews. Continued evaluation of an established plan of care.

Planning: Develops an appropriate patient-specific plan of care to include short and long term goals, objectives and actions. Coordinates, collaborates, and obtains approval of the plan among the patient, family/caregiver, primary provider and other members of the healthcare team.

Advocacy: Provides support for the patient and family/caregivers to ensure identified education and appropriate, timely care is received.

Implementation: Guides the patient and family/care giver through the healthcare system, maximizing use of resources. Coordinates and executes the plan of care, optimizing access to appropriate services. Ensures necessary referrals are ordered by the appropriate discipline and coordinated. Serves as an advocate for, and ensures education is provided to, the patient and family/caregiver as required. Promotes adherence to treatment plans for improved healthcare outcomes.

Coordination: Ensures coordination of care delivery processes, to include alternate healthcare settings and the home environment, for the purposes of enhancing the patient's health and wellness, safety, productivity, and quality of life, and for providing the most beneficial, cost-effective health care. Develops, utilizes and maintains a variety of military and community resources to optimize access to services and medical care. Ensures timely and appropriate provision of services.

Monitoring: Documents and updates the treatment plan as needed in accordance with existing DoD, AF, local facility and other agency guidelines. Maintains documentation and data collection in accordance with DoD, AF, local facility and other specified agency guidelines. Conducts and/or participates in program evaluation as directed.

Evaluation: Monitoring and evaluation may include, but is not limited to: patient's adherence and response to the treatment plan; timeliness of patient and family/caregiver contact and follow-up; identification of variances, patterns or trends from established practice guidelines and/or standards; established outcome measurements; results of interventions, treatment delivery and timeliness of care; and utilization of resources. Monitors and evaluates the facility's case management program per DoD, AF and local policies and guidelines.

Qualifications

Degree/Education (5.2.4): Registered Nurse - Case Manager shall be a graduate from an associate (ADN) or baccalaureate degree (BSN) program in nursing accredited by a national nursing accrediting agency recognized by the US Department of Education.

Certifications in addition to Basic Life Support (5.2.3): Be eligible to obtain a national certification related to Case Management. See Exhibit 5.

Experience: ADN will have a minimum of three years of experience (within the last four years) in full time clinical case management in a hospital or clinic with children, adults, families, seniors, or groups. BSN will have a minimum of two years of experience (within the last four years) in full time clinical case management in a hospital or clinic with children, adults, families, seniors, or groups.