Job Summary: Registered Nurse provides comprehensive nursing case management services for patients with complex medical needs, coordinating multidisciplinary care, assessments, referrals, treatment plans, and transitions of care while ensuring compliance with established standards, BUMED/DHA guidelines, and quality documentation requirements. Serves as a clinical resource and patient advocate by evaluating medical and psychosocial needs, facilitating communication among healthcare teams, patients, and families, tracking outcomes and TBI-related data, and promoting cost-effective, patient-centered care across military and community healthcare settings.
Required Qualifications: - Education: BSN Degree. Graduate from a college or university accredited by National League for Nursing Accrediting Commission (NLNAC), or the Commission on Collegiate Nursing Education (CCNE)
- Certifications:
- Basic Life Support (BLS) and ONE of the following (or must be obtained within 6 months of hire)
- Commission or Case Manager Certification. Certified Case Manager (CCM) or
- Certification of Disability Management Specialist or Certified Disability Management Specialist (CDMS) or
- Commission on Rehabilitation Counselor Certification (CRC) or
- National Board for Certification in Continuity of Care. Advanced Certification in Continuity of Care (ACCC)
- Certified Occupational Health Nurse COHN or COHN S
- Association of Rehabilitation Nurses. Certified Rehabilitation Registered Nurse. (CCRN)
- License: Possess a current unrestricted license to practice as a registered nurse in one of the fifty states, the direct of Columbia, the Commonwealth of Puerto Rico, Guam, or the U.S. Virgin Islands.
- Experience: Minimum of 2 years of inpatient medical-surgical experience or acute rehabilitation within the last three years.
U.S. Citizenship is required
Key Responsibilities: - Implement, manage, and oversee each phase of the Case Management (CM) activities for assigned caseload, and ensure that the CM activities meet established CM standards of care. Continually evaluate overall effectiveness of daily CM operations.
- The HCW will be responsible for delivery of treatment within the personnel and equipment capabilities of the FHCC, provision of mandated medical surveillance and preventive services and the quality and timeliness of treatment records and reports required to document procedures performed and care provided.
- Provide independent nursing expertise in assessment, data collection, and analysis.
- Assess the patient's clinical and psychosocial status, diagnosis and current treatment plan.
- Coordinate the myriad of medical treatments, referrals, and education.
- Assess the needs of patient/family/significant other's related to diagnosis, treatment options, psychosocial impact, and discharge planning.
- Provide a comprehensive range of case management services to inpatients in network facilities, outpatients and their families, with catastrophic illnesses or complex medical needs.
- Plans and provides care to adult patients, provide nursing advice and consultation in person and via telephone/email to patients/family member/significant others. In collaboration with the multidisciplinary team, set patient-centered goals for individual patients/families/significant others. Use critical pathways/ algorithms, databases, and other available resources to develop a comprehensive multidisciplinary plan of care. Collects and tracks data related to TBI and follows the Bureau of Medicine & Surgery (BUMED)/DHA guidelines related to reporting data by documenting all measurable outcomes, and data analysis reports.
- Schedule and coordinate all ancillary services required. Based on the nursing assessment, write the consult referral for the physician's review and signature if needed.
- Ensure consults are completed, results received in a timely manner, and included in the patient's chart. Initiate coordination efforts to ensure smooth transition and continued health care treatment to patients when the military member/beneficiary transfers out of the area. Assist with region-to-region transfers.
- Effectively collaborate with all levels of the health care team. This includes, but is not limited to clinics, inpatient facilities, physicians, nurses, other health care providers such as social workers, psychologists, psychiatrists, physical, occupational, speech or respiratory therapists, dieticians or nutritional counselors, pharmacists, durable medical equipment providers, home health care providers, and other outpatient departments, ancillary services, community resources, etc.
- Establish and maintain liaison with appropriate FHCC staff, community agencies and organizations to include the TRICARE East, BUMED/DHA, Navy VA Hospitals, and the Managed Care Support Contractor Case Managers.
- Serve as a resource to physicians, nurses and other professional personnel at other medical treatment facilities used as referral sources for patients. Share experience, knowledge and skills.
- Plan for personal growth as related to professional goals based on self-assessment, evaluation, and feedback. Assume responsibility for acquiring knowledge and experience to meet goals. Actively participate in professional organizations. Conduct training in case management for professional and paraprofessional personnel within the department and command.
- Implement tools to support case management, such as those used for patient identification and patient assessment, clinical practice guidelines, CM software, and develop a database for local community resources.
- Intervene when variances occur in a patient's individualized treatment plan.
Coordinate and evaluate the patient's and family's use of resources and services in a quality conscious, cost-effective manner. Follow cost containment/cost avoidance strategies for
case management and develop mechanisms to measure cost effectiveness. Coordinate
access to appropriate community programs and resources. - Participate in Performance Evaluation and Improvement (PE & I) activities by
evaluating patient care systems that may include standards, protocols, and documentation
for efficiency, safety, and quality. Incorporate evaluative data in the provision of ongoing
case management services. Provide staff education as appropriate. - Ensure instruction to the patient and the family based on identified learning needs.
Assess the family's knowledge base, health status expectations, and the potential for the
family member acting as the primary care giver if necessary. - Assist with the development
of activities and methods to ensure information is articulated and disseminated to staff. - Collaborate with the health care team, community agencies, and other providers
within and outside the command to ensure continuity of the patient's care through all health
care settings. - Promote effective communication among health care team members, including the patient, family, and significant others.
- Participate in frequent team meetings. Integrate all recommendations of the multidisciplinary team members into a single plan of care.
- Based on patient needs, ensure appointments are made for patients per standard of
care, when necessary, advice is provided over the telephone, patients are referred to other
medical treatment facilities or clinics, and patients are continually triaged to ensure the
most seriously ill are seen expediently, regardless of appointment schedules. - Collects and tracks data related to TBI and follows BUMED/DHA guidelines related to reporting data.
Work Environment & Schedule: Monday- Friday, 6:30am - 4:30pm plus unpaid lunch break.
Compensation & Benefits: Up to $ 55.08 per hour + $5.09 H&W
