Job Description
Job DescriptionDescription:
Clinical Registered Nurse, Case Manager
• Degree/Education (5.2.4): Associates degree in Nursing from an accredited institution.
• Certifications in addition to Basic Life Support (5.2.3): BLS for Healthcare Providers through either American Heart Association or American Red Cross. (Online certifications are not acceptable)
• Experience: Shall have a minimum of two (2) years with the past five (5) years. The experience shall have been in primary care clinic or case management setting.
• Board Certification (5.2.6.4.4): A certification is highly recommended but not required.
• Licensure/Registration: Current, Full, active, unrestricted nursing license.
HCW Duties (5.1 Task 1): The duties for the HCW are as follows: Case Managers, in addition to Exhibit 5:
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.
5.1. The case manager (CM) nurse will comply with the standards and processes in 6025.11, DHA-PI 6025.19, DHA-IPM 18-001, DHA-IPM 19-004, Utilization of the Case Management (CM) Registry (Active and Screening) for Military Health System (MHS) Beneficiaries, and this instruction.
5.2. The CM nurse will 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-PI 6025.19 and AFI44-173.
5.3. The CM nurse should provide CM and/or care coordination to these patients and develop and execute an individualized multi-disciplinary care plan in conjunction with patient and family in accordance with accepted standards. The CM nurse should provide the patient and family a copy of this individualized care plan.
5.4. The CM nurse is expected to document CM interventions, care coordination, and outcomes in patient’s EHR and maintain a registry of all patients receiving CM services.
5.5. The CM nurse should provide AFMH staff training on CM programs. The CM nurse is expected to collaborate with PCM teams on CM activities. nurse is expected to maintain a current registry of patients to whom CM services are being provided. The CM nurse should 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.
5.6. The CM nurse should provide routine updates and outcome metrics on AFMH Patients enrolled in CM programs to PCM teams.
5.7. The CM nurse will provide care coordination guidance and mentoring to AFMH Staff who provide these services for their empaneled patients.
5.8. The CM nurse should educate AFMH staff on CM nurse role.
5.9. The CM nurse will attend and participate in AFMH team huddles, care coordination meetings, population health, and transition of care meetings.
Requirements:
Minimum Qualifications:
Degree: Associates Degree of Nursing.
Education: Graduate from a college or university accredited by Accreditation Commission for Education in Nursing (ACEN), the Commission on Collegiate Nursing Education (CCNE) or as otherwise outlined in the TO.
Certification: Possess one of the following certifications: Basic Lie Support (BLS)
Experience: Shall have a minimum of two (2) years with the past five (5) years. The experience shall have been in primary care clinic or case management setting.