Responsibilities
- 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.
Qualifications
- Education. Shall be a graduate of a nationally accredited Associates Degree, Diploma, or Baccalaureate Degree program in nursing. Baccalaureate Degree is preferred.
- License/certfcation. 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.
- Experience. Shall have at least 4 years of active nursing practice, 18 months of which must be in discharge planning or clinical case management for adults, children, families, seniors or groups. Must have worked in nursing the past 12 months. Home Health experience desirable.
- Certification. Certification in Case Management from the American Nurses Credentialing Center or the Commission for Case Management Certification is desired.
- Work Environment/Physical Reouirements. Requirements include prolonged walking, standing, sitting or bending, and computer use. Position may require patient visitation at another medical treatment facility. May have exposure to communicable illnesses.
