Registered Nurse - Case Management w/sign-on bonus - 5389

Registered Nurse - Case Management

We have an urgent need for a Registered Nurse - Case Management at Luke Air Force Base in Glendale, Arizona. Position Summary: Provides case management, care coordination and discharge/disposition planning for inpatient and outpatient care settings. Assists service members and/or veterans, family members and caregivers with receiving the most appropriate options and services to meet their complex health care needs. This includes, but is not limited to, acute, chronic, multiple, complex, catastrophic, or life-threatening illnesses; combat stress, residuals of traumatic brain injury; community adjustment; addictions and other health problems. Coordinates care with multiple providers across all levels and sites of care. Addresses psychosocial, as well as nursing and medical needs of patients and their families/caregivers, through participation in multidisciplinary patient care management practice. Evaluates care and outcomes to ensure timely and appropriate provision of services.

Job Specific Details and Tasks:

Assessment. Proactively identifies and evaluates patients and families for case management 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 contact and other relevant sources such as professional and non-professional caregivers, medical records, family/caregiver interviews.

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.

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.

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.

Must maintain a level of productivity and quality 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); CAMH; (AAAHC); Health Services Inspection (HSI); 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.

Follows applicable local facility/AF/DoD instructions, policies and guidelines. Completes medical record documentation and coding, and designated tracking logs and data reporting as required by local facility/AF/DoD instructions, policies and guidance.

Completes all required electronic medical record training, facility-specific orientation and training programs, and AF/DoD mandated Case Management training.

Core Duties:

Participate in all phases of the Case Management Program (CMP) and ensure that the CMP meets established case management (CM) standards of care.

Provide nursing expertise about the CM process, including assessment, planning, implementation, coordination, and monitoring. Identify opportunities for CM and identify and integrate local CM processes.

Develop and implement local strategies using inpatient, outpatient, onsite and telephonic CM

Develop and implement tools to support case management, such as those used for patient identification and patient assessment, clinical practice guidelines, algorithms, CM software, and databases for community resources.

Integrate CM and utilization management (UM) and integrating nursing case management with social work case management.

Maintain liaison with appropriate community agencies and organizations. Accurately collect and document patient care data.

Develop treatment plans including preventive, therapeutic, rehabilitative, psychosocial, and clinical interventions to ensure continuity of care toward the goal of optimal wellness.

Establish mechanisms to ensure proper implementation of patient treatment plan and follow-up post discharge in ambulatory and community health care settings.

Provide appropriate health care instruction to patient and/or caregivers based on identified learning needs.

Schedule: Monday - Friday, 9 hours between 7:00am and 5:30pm, with a one hour unpaid lunch. No weekends or holidays.