- Participate in all phases of the Case Management Program (CMP) and ensure that the CMP meets established case management (CM) standards of care.
- Maintain adherence to Joint Commission, URAC, Case Management Society of America (CMSA), and other regulatory requirements. Apply medical care criteria (e.g., InterQual).
- Provide nursing expertise about the CM process, including assessment, planning, implementation, coordination, and monitoring.
- Integrate case management (CM) with utilization management (UM) and disease management as needed. Integrate nursing case management with social work case management.
- 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.
- Maintain liaison with appropriate community agencies and organizations.
- Provide input on hospital CM resources and make recommendations to the Command as to how those resources can best be utilized.
- Work in conjunction with the entire healthcare team and other departments, to identify high-risk and/or high-utilizer populations to include but not limited to those beneficiaries with multiple providers, multiple admissions/readmissions, Emergency Department visits, catastrophic illness, chronic or terminal illness, and multiple medical problems/dual diagnoses.
- Collaborate with other members of the healthcare team, the patient and/ family/support system on a regular basis to establish and update the case management plan of care using evidenced-based guidelines (when available and/or applicable).
- Identify measurable short-and long-term goals/outcomes of care with matching strategies to achieve optimal wellness and autonomy (self- management). Incorporate the patient s cultural background, values and beliefs, readiness to learn and healthcare needs across the continuum of care into the plan.
- Provide the patient/ family with the knowledge and skills necessary for the implementation of the established plan. Facilitate patient and family decision-making activities by keeping them well informed of their rights, responsibilities and options. When indicated, follow patients through hospitalization and follows up in ambulatory and community health care settings.
- Actively measure the patient s response to the evidence-based plan of care and provide documentation that the plan and the quality of the services offered to the patient correspond to the identified needs.
- Facilitate multidisciplinary discharge planning and other professional staff meetings as indicated for complex patient cases and develop a database and knowledge of local community resources.
- Develop and implement mechanisms to evaluate the patient, family and provider satisfaction and use of resources and services in a quality-conscious, cost-effective manner.
- Collaborate with the multidisciplinary team members to set patient-specific goals. Develop treatment plans including preventive, therapeutic, rehabilitative, psychosocial, and clinical interventions to ensure continuity of care toward the goal of optimal wellness.
- Close cases when goals are met, patient declines service, patient transitions to another case manager or patient needs are no longer identified.
- Facilitate and coordinate strategies to ensure smooth transition and continued health care treatment for patients when the military member transfers out of the area. Develop a policy for, and assist with, region-to-region transfers. This shall include coordination of required tests, procedures, treatments, discharge planning, community referrals, and transfers.
- Facilitate screening and assist with transfers of Exceptional Family Member Program (EFMP) families and service members going through the Integrated Disability and Evaluation System (IDES).
- Keep informed of research and new information that will ensure new methods and practices are incorporated into the case management program.
- Facilitate command cost containment through proper utilization of available resources and timely assessment of patient response to the case management program.
- Perform clinical assessments of the patients and managed care records that include clinical input from various health care providers across all clinical areas.
- Perform follow-up clinical assessments to ensure the effectiveness of treatment plans in place.
- Accurately collect and document patient care data.
- Operate and manipulate automated systems such as CHCS, AHLTA, ADS, Essentris, and Clinical Information System (CIS)
- Degree: Associates Degree of Nursing.
- Education: Graduate from a college or university accredited by Accreditation Commission for Education in Nursing (ACEN), or The Commission on Collegiate Nursing Education (CCNE).
- Possess two years of case management experience within the last three years.
- Certification: Possess one of the following certifications:
- Commission for Case Manager Certification Certified Case Manager (CCM)
- Certification of Disability Management Specialists Commission: Certified Disability Management Specialist (CDMS)
- Association of Rehabilitation Nurses: Certified Rehabilitation Registered Nurse (CRRN)
- American Board for Occupational Health Nurses Certified Occupational Health Nurse (COHN) or Certified Occupational Health Nurse-Specialist (COHN-S).
- National Board for Certification in Continuity of Care: Advanced Certification in Continuity of Care (ACCC)
- Commission on Rehabilitation Counselor Certification: Certified Rehabilitation Counselor (CRC)
- American Nurses Credentialing Center Nurse Case Manager (RN-NCM)
- National Academy of Certified Care Managers: Care Manager Certified (CMC)
- OR
- Possess a minimum of 2 years full-time experience within the last 3 years as a registered nurse providing case management and obtain one of the eight certifications, above, within six months of hire.
- Current, full, active, and unrestricted license to practice as a Registered Nurse as required in the TO.
- Possess and maintain BLS.
- Must be a U.S. Citizen (for access to Gov't computer systems)
- COMPENSATION & BENEFITS:
- Salary $53.04/hr.
- Health and Welfare $4.41/ hr. Health & Welfare allowance covers the cost of health insurance, if needed. Cash in lieu of.
- $1,000 CEUs
- 10 days paid vacation per year.
- 7 sick days per year
- 11 days paid Federal holidays.
- Vision, Dental, and 401(k) plans available
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Description
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