Registered Nurse - Wounded Warrior Case Manager w/bonus - 5356

Registered Nurse - Wounded Warrior Case Manager

We have an urgent new need for a Registered Nurse - Wounded Warrior Case Manager at Maxwell Air Force Base in Montgomery, AL.

Core Duties: The duties include, but are not limited to the following:

Proactively identify candidates for case management (CM) or care coordination services using analytic tools, predictive analytics, and CM registries. Referrals may also come from the PCM/interdisciplinary healthcare team.

Wounded Warrior Case Manager - This CM role is dedicated primarily to the active duty wounded, ill, and injured (WII) population, but this role offers flexible capacity to support non-WII patients based on operational demand.

Identify individuals with chronic, catastrophic, complex, high utilization, high-risk, or high-cost health issues who would benefit from CM services and notify PCM teams, in accordance with DHA-AI 6025.39.

Provide CM and/or care coordination to these patients: Assess the patients' needs, develop personalized care plans, and facilitate access to necessary healthcare services and community resources.

Provide education to patients and their families. Advocate for the patient's needs to ensure timely and appropriate delivery of care.

Collaborate with PCM teams on CM activities. Provides routine updates and outcome metrics on patients enrolled in CM programs to PCM teams.

Provide behavioral health (BH) CM services and follow-up communications to eligible BH patients, in collaboration with the MTF Behavioral Health Lead, IAW DHA-AI 6025.39.

Document all CM or care coordination encounters within the patient's EHR using proper coding and data capture IAW MHS coding guidance and DHA AI 6025.39. Document patient interactions, referrals, and care plans to maintain consistency and track progress.

Maintain a current registry of all patients receiving CM services. Coordinate with the PCM team staff members about patients moving into CM care (into the registries) and graduating from primary CM care back to the team (off the registries) and document such in an EHR note.

Provide CM/care coordination training, guidance, and mentoring to MTF personnel who utilize these services in their empaneled patients.

Participate in the facility Medical Management, Population Healthy, Quality, and care coordination meetings as well as appropriate DHA or network webinars, meetings, or work groups.

Work Schedule:

Monday - Friday, 9 hours between 7:00am and 5:00pm, including a one hour lunch