RN Disease Manager

Akahi Associates/Kako'o Services, LLC•Biloxi, MS

1d•Onsite

About The Position

The RN Disease Manager will provide comprehensive Disease Management (DM) services, applying and promoting DM, health promotion, and wellness concepts and strategies to assigned patients. This role involves assessing, planning, developing, coordinating, implementing, and evaluating preventive and clinical services for beneficiaries across the population health continuum. The position requires implementing disease management services for populations with chronic conditions, collaborating with patients on goals, and educating individuals and groups based on clinical practice guidelines. Proactive collaboration with patients and healthcare teams, utilization of evidence-based tools like predictive analytics, and thorough patient evaluations are key. The goal is to promote self-management, prevent disease progression, improve outcomes, and advocate for appropriate resource utilization. The role also involves facilitating the adoption of standardized clinical practice guidelines, educating teams on their utilization, and identifying/developing multidisciplinary disease management activities. Performance measurement, data reporting, and developing annual disease management plans are also responsibilities. Direct person-to-person summaries for patient transitions and documentation using specific coding systems are required. Participation in interdisciplinary meetings, committees, and continuing education is expected, along with maintaining productivity and quality standards in accordance with various guidelines and policies.

Requirements

Registered Nurse – Disease Manager 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.
Be eligible for any national recognized disease or chronic care management certification.
Minimum two years of recent full-time experience (within the last four years) in management of patient populations with prevalent and chronic diseases.
Current, full, active, and unrestricted license to practice as a Registered Nurse as required in the TO.
Basic Life Support certification.

Responsibilities

Provides comprehensive Disease Management (DM) services, applies and promotes DM, health promotion, and wellness concepts and strategies to assigned patients and those identified for DM.
Assesses, plans, develops, coordinates, implements, and evaluates preventive and clinical services for all assigned beneficiaries covering comprehensive primary, secondary, and tertiary prevention/intervention across the population health continuum ranging from normal to those having complex complications.
Implements disease management services for populations with chronic conditions, collaborates with patients in formulating patient-centered goals, and educates individuals and groups based on clinical practice guidelines (CPGs) approved by the Executive Committee of the Medical Staff.
Proactively collaborates with the patient and healthcare teams, and utilizes evidence based tools, such as predictive analytics, to identify patients who would benefit from disease-specific education and patient-centered care. Conducts a thorough evaluation of the patient’s current physical, psychosocial, and health status. Documents treatment plans and matches the level of patient care to clinical risk, readiness to change, and health literacy. The goal is to promote self-management, prevent or delay the progression of disease, improve clinical and financial outcomes, and advocate appropriate resource utilization.
Facilitates identification, adoption, implementation and utilization of standardized CPGs and protocols for management of specific diseases and conditions. Educates/trains teams/staff on policies and procedures for the utilization of guidelines, protocols, and other disease management activities.
Identifies, develops and executes appropriate multidisciplinary disease management activities and interventions in collaboration with the Chief of Medical Staff, Chief Nurse, Health Care Integrator, Medical Management Director, Behavioral Health Care Facilitator, Case Manager, Utilization Manager, Discharge Planner, Group Practice Manager, and primary/specialty care teams in support of population health and population health management initiatives.
Identifies, collects, interprets, and evaluates measurable outcomes of care within established time frames (e.g., quality of services, cost and cost savings, disease management, and continuous process improvement). Conducts special studies as indicated based on outcomes and other Quality Management/Risk Management and Population Health programs and indicators.
Reports data as required in coordination with the Health Care Integrator/Medical Management Director and Chief of Medical Staff. Reports disease management-related data, process and outcome measures, identified opportunities for improvement, status of process improvement programs and other requested information to MTF leadership through committees, such as Population Health Working Group. Develops and evaluates the annual disease management plan for inclusion in the population health plan in collaboration with stakeholders.
Provides a direct person-to-person summary (i.e., verbal communication providing continuity of care and a seamless transfer of information) of patients transitioning to other levels or places of care by providing pertinent information to the receiving healthcare provider (e.g., patient self-management status at graduation from the disease management program to primary care team, or transfer to case management for more sensitive services); documents direct person-to-person summary in the electronic health record.
Documents disease management-related care provided using the ELAD Medical Expense and Performance Reporting System (MEPRS) code for all face-to-face, telephonic, or TRICARE Online Patient Portal Secure Messaging interactions. Coding will include current International Classification of Diseases (ICD), Evaluation and Management (E&M), and disease management-specific Healthcare Common Procedure Coding System (HCPCS) codes, and the encounters must be completed and signed within three business days.
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 disease management. Participates in the orientation, education, and training of other staff. Orients healthcare teams to the purpose of DM activities, population health, clinical preventive services, and medical management.
May participate in committees, working groups, and task-forces at the MTF. Completes all required training and competency verification programs in accordance with (IAW) DHA, Air Force Medical Operations Agency, and MTF-level guidance. Participates in continuing education programs to update and maintain skills and knowledge to meet annual requirements.
Conducts standardized peer review or gap analysis as directed by DHA/AF guidance, under the Chief Nurse’s approval.
Maintains 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; designated VA/DoD Clinical Practice Guidelines, American Diabetes Association, and other evidence-based disease management professional guidelines; Accreditation Association for Ambulatory Health Care (AAAHC); Utilization Review Accreditation Commission (URAC); Health Services Inspection (HSI); Joint Commission; and other applicable DoD/DHA/AF/MTF and service-specific guidance and policies. Must comply with Equal Employment Opportunity (EEO) Program, infection control and prevention, and patient safety policies and procedures.