(Archived) RN Case Manager- Malmstrom AFB, MT

CLINICAL NURSE CASE MANAGER
Malmstrom AFB, Great Fall, MT
M-F 7:30 AM - 4:30 PM

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.

1. QUALIFICATIONS

1.1. 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.

1.2. 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.

1.3. Must be skillful and tactful in communicating with people who may be physically or mentally ill, uncooperative, fearful, emotionally distraught, and occasionally dangerous.

1.4. Must possess organization, problem-solving and communication skills to articulate medical requirements to patients, families/care givers, medical and non-medical staff in a professional and courteous way.

1.5. Education. Shall be a graduate from an associate (ADN) or baccalaureate degree (BSN) program in nursing accredited by a national nursing accrediting agency recognized by the US Department of Education.

1.6. License. Maintain an active, valid, current, and unrestricted license (with no limitations, stipulations or pending adverse actions) to practice nursing as a registered nurse in any US state/jurisdiction.

1.7. Experience. A minimum of 3 years for ADN or 2 years for BSN full-time experience in clinical case management working with adults, children, families, seniors and groups.

1.8. Certification. Certified Case Manager by Commission for Case Management (CCM) or American Nurses Credentialing Center (ANCC) -OR- certification eligible with 3 years of experience for ADN or 2 years experience for BSN in full time clinical case management with children, families, seniors, or groups.

2. TYPE OF WORK. The duties include but are not limited to the following:

2.1. 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.

2.2. 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.

2.3. 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.

2.4. 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.

2.5. 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.

2.6. 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.

2.7. 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 IAW Para 2.4.1 of the Contract.

2.8. 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.

2.9. Participates in the orientation and training of other staff. May serve on committees, work groups, and task forces at the facility.

2.10. 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.

2.11. Follows applicable local MTF/AF/DoD instructions, policies and guidelines.

2.12. Completes medical record documentation and coding, and designated tracking logs and data reporting as required by local MTF/AF/DoD instructions, policies and guidance.

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