Registered Nurse Case Manager

• Paid Vacation, Paid Sick Time, and 12 Paid Federal Holidays!
• Medical/Dental/Vision, STD/LTD/Life, and Health Savings Account available!
• Annual CME Stipend and License/Certification Reimbursement!
• Matching 401K!

• Must possess organization, problem-solving and communication skills to articulate medical requirements to patients, families/care givers, medical and nonmedical staff in a professional and courteous way.
• Must have the knowledge and skills to effectively apply the following core case management functions: a) Assessment: Identification of patients for case management; comprehensive collection of patient information and medical status; and continued evaluation of an established plan of care; b) Planning: Collaboration with the patient, family/caregiver, primary provider and other members of the health care team for developing an effective plan of care; c) Facilitation: Care coordination and communication among all involved parties; d) Advocacy: Support for the patient and family/caregivers to ensure identified education and appropriate, timely care is received.
• Must be skillful and tactful in communicating with people who may be physically or mentally ill, uncooperative, fearful, emotionally distraught, and occasionally dangerous.
• Must be knowledgeable in medical privacy and confidentiality (Health Insurance Portability and Accountability Act [HIPAA]); accreditation standards of Accreditation Association for Ambulatory Health Care (AAAHC) and The Joint Commission (TJC); and computer applications/software to include Microsoft Office programs, MS Outlook (e-mail), and internet familiarity is required.
• Identification of patients for case management; comprehensive collection of patient information and medical status; and continued evaluation of an established plan of care.
• Conduct CM staff peer reviews, using approved peer review form as assigned.
• Proactively implement CM services for populations with chronic conditions, collaborate with beneficiaries in formulating patient-centered goals, and educate individuals, their families or caregivers.
• Provide a warm handoff (person-to-person verbal communication providing continuity of care and a seamless transfer of information) of patients in transition to other levels or places of care by providing pertinent information to the receiving health care provider document warm handoff communications.
• Serves as patient advocate and liaison to healthcare and community agencies for matters concerning primary, secondary, and tertiary healthcare services. Actively participates as team member or facilitator of committee or working group.
• Attend multidisciplinary rounds, ward meetings/discharge planning meetings as required to ensure multidisciplinary collaboration and optimal effective communication.
• When possible ensure the patients families and care givers are involved in the case management process. Act as a point of contact when there are complex arrangements to be organized for patients.
• Completes and appropriately documents an assessment of patient, family and caregiver readiness, identifies individual health care needs, and proactively coordinates chronic condition care follow-on care.
• Be able to perform with minimal supervisory direction. Be able to independently identify, plan, and carry out projects with consideration for the goals and objectives of the MTF’s Utilization Management and Medical Management Departments.
• 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, Defense Health Agency (DHA), 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, DHA and local policies and guidelines.
• Travel: Travel outside of the local MTF and/or off the military installation may be necessary. When needed, travel to the patient's military living quarters during inspections to inspect and advocate for the patient's medical and special physical requirements and to verify that the housing being provided is safe, accessible, and facilitates the care and recovery of the member. Travel will be reimbursed.
• 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 MTF/DHA/AF/DoD instructions, policies and guidelines.
• Completes medical record documentation and coding, and designated tracking logs and data reporting as required by local MTF/AF/DHA/DoD instructions, policies and guidance.
• Completes all required electronic medical record training, MTF-specific orientation and training programs, and AF/DoD/DHA and locally mandated Case Management training; participates in continuing education programs to update and/or maintain license.

• Education: Graduate from an accredited professional nursing educational program.
• Experience: Twelve (12) months of recent full-time experience in nursing/health care management for adults, children, families, seniors, or groups is required.
• Licensure: Current, full, active, and unrestricted nursing license from any state
• Clinical Certification: Possess one of the following certifications: American Nurses Credentialing Center (ANCC), Nurse Case Manager (RN-NCM), National Academy of Certified Care Managers: Care Manager Certified (CMC) OR Commission for Case Manager Certification (CCMC): Certified Case Manager (CCM) or American Nurses Credentialing Center (ANCC) -OR- have practiced the equivalent of 2 years full-time as a Registered Nurse, and have a minimum of 2,000 hours of clinical practice in nursing case management within the last 3 years, and have completed 30 hours of continuing education in nursing case management within the last 3 years.
• Life Support Certification: Possess current AHA or ARC Basic Life Support
• Security: Must possess ability to pass a Government background check/security clearance.

Pay Scale: $51.17 - $80.00 per hour, to be determined based on qualifications, experience, and location.