Registered Nurse Case Manager
Description

REGISTERED NURSE. Perform a full range of RN duties in accordance with assignment under the task order, including: triage; patient assessment and monitoring; use of patient monitoring and treatment equipment; appropriate nursing care, procedures, and treatments; execution of physicians’ orders within the guidelines of standard nursing practice; documentation of patient care and observations; and patient education and emotional support.

Assess each patient and perform triage duties as assigned.

Formulate and carry out a goal directed plan of care which based on determined nursing diagnosis and patient outcomes and which is prioritized according to patient needs and available resources including time, personnel, equipment, and supplies.

Evaluate effectiveness of self-care given by all health team members, and contribution of systems, environment, and instrumentation in progressing patient toward outcomes.

Provide treatment and discharge instructions upon patient release.

Perform assessment/data collection in an ongoing and systematic manner, focusing on physiological, psychological, and cognitive status.

Provide a safe and clean environment for each patient.

Identify patient/significant other learning needs and implement appropriate measures to meet identified needs.

Assist in planning, provide clinical guidance and provide instruction to LPNs/LVNs, nursing assistants and ancillary personnel.

Demonstrate sound knowledge base and action in the care and decision making for designated patient populations. If weaknesses or deficiencies are identified either by peer reviews, quality control reports (QCRs), or evaluations the HCW will be required to complete refresher training (in-services, competency reviews, continuing education, etc.) at Contractor expense.

Perform documentation (manually and/or by use of computer) duties on unit and in-patient record that are timely, accurate, and concise.

Participate actively in staff development for unit and Directorate personnel and evaluation of personnel.

Seek validation of knowledge base, skill level, and decision making as necessary and assertively seek guidance in areas of question.

Implement care in a knowledgeable, skillful, consistent, and continuous manner.

Establish priorities of patient care based on essential patient needs and available unit, command, and community resources including time, personnel, equipment, and supplies.

Demonstrate competency in medication and intravenous (IV) administration to include blood products and Total Parental Nutrition (TPN) intramuscular (IM) and subcutaneous (SQ) administration and demonstrate competency in phlebotomy as specific to the position.

Safely administer prescribed medications to include intravenous drips and intravenous push drugs.

Identify patient/significant other learning needs and implement appropriate measures to meet identified needs.

Perform documentation (manually and/or by use of computer) duties on unit and in-patient record which are timely, accurate, and concise.

Participate actively in multifaceted staff development activities at the unit, Director, and command level, such as teaching formal and informal classes, acting as a role model, educator and mentor to new paraprofessional personnel with the goal of helping them successfully complete competency based skills list and weekly goal setting, assisting in the Command’s Basic Cardiac Life Support classes and promoting staff competency and efficiency in emergent situations, and by participating in cross-training initiatives.

Demonstrate self-directed learning. 

Participate in development and attainment of unit and Nursing Directorate goals. 

 

Demonstrate effective and professional communication methods, and skills, using lines of authority appropriately.

Formulate and use effective working relationships with all health care team members, patients, and significant others. Refer unsolved complaints or infractions to the Division Head with recommendations for appropriate action

Practice effective problem identification and resolution skills as a method of sound decision making.

Remain flexible in staffing patterns and resolution of staffing conflicts; participate in temporary assignment measures.

Provide individual, group, and family/significant other counseling and health teaching in relation to the patient's condition and his/her ability for self-care. Provide for accessibility to various literature resources dealing with subjects related to specific patient health problems. Provide physical and psychological support to patients and significant others, explain procedures and treatments, and promote cooperation among staff, patients, and significant others.

Participate in the orientation and training of newly assigned unit personnel. Participate in cross-training initiatives.

Provide input into competency assessments of newly assigned unit personnel.

Collaborate in the review of clinic standing operating procedures.

If directed, perform phone triage based on accepted protocols and assist as needed in accessing appropriate ambulatory/emergency care for beneficiaries.

Provide training and/or technical guidance as applicable to supporting Government employees (i.e. hospital corpsmen, technicians, students) assigned to the HCW during the performance of clinical procedures. Such guidance and interaction will adhere to Government and professional clinical standards and accepted clinical protocols.

Participate in all phases of the Case Management Program (CMP) and ensure that the CMP meets established case management (CM) standards of care. Assist in coordinating a multidisciplinary team to meet the health care needs, including medical and/or psychosocial management, of specified patients.

Serve as consultant to all disciplines regarding CM issues. 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 policies and protocols for home health assessments and outcome measures.

Develop and implement tools to support case management, such as those used for patient identification and patient assessment, clinical practice guidelines, algorithms, CM software, databases for community resources, etc.

Integrate CM and utilization management (UM) and integrate nursing case management with social work case management. Prepare routine reports and conduct analyses.

Assist in establishing and maintaining liaison with appropriate community agencies and organizations, the Defense Health Agency (DHA), and the Managed Care Support Contractor.

Maintain adherence to Joint Commission, Utilization Review Accreditation Commission (URAC), Case Management Society of America (CMSA), and other regulatory requirements. Apply medical care criteria (e.g., InterQual).

Assist with collecting and analyzing baseline data and ongoing outcomes to support continuous quality and cost-effective improvement. Identify gaps in existing services and assists in the development and implementation of appropriate services in a timely and cost-effective manner based on extensive knowledge of case management principles and established standards of care. Trend variances and address them to support continuous quality improvement. 

Provide input on MTF CM resources and make recommendations to the Command as to how those resources can best be utilized. 

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.

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.

Identify and select clients who can most benefit from case management services available in a particular practice setting. 

Establish and implement mechanisms to ensure proper implementation of patient treatment plan and follow-up post discharge in ambulatory and community health care settings.

Provide case management advice and consultation

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.

Ensure appropriate health care instruction to patient and/or caregivers based on identified learning 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.

Provide case management orientation and education for other case managers new to the role and/or facility providing scientific and practice-based knowledge per the Case Manager Core Competencies.

Provide support to other case managers, including managing caseloads during absences.

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).

Plan for professional growth and development as related to the case manager position and maintenance of CM certification. Actively participate in professional organizations including participation in at least one (1) annual national CM conference to be funded by the Government to be scheduled at the convenience of the Government and the HCW. Ensure all training completion documentation is submitted to the region and headquarters (HQ), as required. Conference approval is subject to the availability of funds.

Participate in video teleconferences (VTCs) and other meetings as required.

Provide safe, quality clinical case management services to a variety of eligible beneficiaries, in accordance with the Department of Defense (DoD), BUMED, Regional, directorate, and departmental instructions, policies and procedures.

Keep informed of research and new information that will ensure new methods and practices are incorporated into the case management program; attends continuing education programs, seminars, and conferences in order to maintain core competencies in case management. 

Facilitate command cost containment through proper utilization of available resources and timely assessment of patient response to the case management program.

Assist in the design, implementation, sustainment and ongoing improvement of the case management program.

Increase MTF staff involvement in and support of case management initiatives by providing orientation and ongoing education and in-service training specific to case management and the program.

Requirements


Requirements

Be a graduate of a school of nursing accredited by the Accreditation Commission for Education in Nursing (ACEN), or the Commission on Collegiate Nursing Education (CCNE) that conferred a nursing baccalaureate or an advanced nursing degree and possess and maintain one or more of the certifications listed below:

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)

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


Be a graduate of a school of nursing accredited by the Accreditation Commission for Education in Nursing (ACEN), formerly known as the National League for Nursing Accrediting Commission (NLNAC), or the Commission on Collegiate Nursing Education (CCNE) that conferred a nursing baccalaureate or an advanced nursing degree and possess a minimum of six (6) months of case management experience within the preceding thirty six (36) months and obtain any of the above certifications listed in C.8.5.3.1. within six (6) months of commencing performance.


PM18

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