RN-Disease Manager

Akahi Associates•Nellis AFB, NV

About The Position

Overview Location: Nellis AFB Pay: $60/hr Schedule: Monday-Friday between the hours of 0700- 1800, dependent upon mission requirements: 8 hour work days 5 days per week or 10-hour work days 4 days per week. To take a 30 min - 1 hour uncompensated lunch. The work hours are dependent upon the mission requirements. Overage Hours: Overage hours for each labor category are as follows: Will start with 5 OT and will not exceed 25 hours per FTE per year. Benefits: Vested vacation, sick leave, holiday leave, Life, Accidental Death and Dismemberment, Short Term Disability Optional Benefits: Medical, Dental, Vision, 401(K) matching with employee participation in 401(K) plan Responsibilities Knowledge of managed care principles, military and civilian population healthcare, case management, utilization management, and demand management functions is highly desired. In collaboration with medical and nursing peers, develops innovative, and/or unique treatment programs to best provide advanced level, specialized, and comprehensive professional nursing care to high- and low-risk patients with diseases/conditions across the healthcare continuum appropriate for disease management interventions. Prioritizes patients in the disease management program. Assesses and identifies individual patient care needs and provides the type and amount of care required to meet the individual needs of each patient, making independent nursing diagnoses, providing health care instructions and/or appropriate referral to a provider or other department. Performs proactive patient management and education. Supports the provider/patient relationship and plan of care, emphasizes prevention of exacerbations and complications utilizing evidence based practice guidelines and patient empowerment strategies. Empowers and prepares patients to manage their health and become active participants to meet their healthcare needs. Organizes internal and community resources to provide ongoing self management support to patients. Utilizes proven programs to provide health information, emotional support, and strategies for living with chronic illness. Collaborates with providers and patients to define problems, set priorities, establish goals, create treatment plans and implement solutions. Interprets and evaluates data appropriately in collaboration with Health Care Integrator and Group Practice Manager. Provides highly specialized, comprehensive primary, secondary, and tertiary prevention/intervention nursing services to active duty/reserve/retired military members and their families. Professional nursing care/treatment will include patients of all ages and may be conducted via clinic, office, telephone, and electronic contact. Provides advanced nursing services to patients across the population health continuum ranging from normal to those having complex complications requiring sophisticated, highly technical care and treatment. Assesses, plans, develops, coordinates, implements, and evaluates preventive and clinical services for all assigned beneficiaries, to include but not limited to: Taking health histories, evaluating annual and fitness health conditions which cause or exacerbate clinical disease, patient and family advocacy, role modeling, performing telehealth nursing, patient assessments and triage of diverse patient symptoms, health screening, acute, routine, wellness, emergency care, a variety of treatments and diagnostic procedures, and medication and immunization administrations. Ability to recognize adverse signs and symptoms and quickly react in emergency situations. Initiates and coordinates referrals to other healthcare providers, services, or agencies. Collaborates with military, base, community and civilian agencies, and TRICARE to ensure coordination of services and continuity of care. Makes necessary judgments to safely administer immunizations/medications based on knowledge of their effects on the physiological processes and current conditions of the patient. Administers medications and immunizations via multiple routes, as appropriate. Maintains continual awareness of unusual dosages of medications/immunizations and calls unusual dosages to the attention of the provider. Prepared to manage adverse medication/immunization reactions; documents and submits appropriate reports. Coordinates mail-order prescription requests. Ensures compliance with professional standards of care and practice (i.e., American Academy of Ambulatory Care Nursing (AAACN), The Joint Commission (TJC), Accreditation Association for Ambulatory Health Care (AAAHC), Health Services Inspection (HSI), Occupational Safety and Health Administration (OSHA), DoD Health Information Privacy Program, the Health Insurance Portability and Accountability Act (HIPAA), etc.) Prepares health program maintenance, submission of reports, and assists in writing clinic policies and procedures as assigned. Participates in Quality Improvement and Risk Management activities. Utilizes evidence-based research in daily practice. Applies community and population health management principles and processes. Identifies candidates for disease management using the Military Healthcare System Population Health Portal, Integrated Clinical Database, Complex Patient Management Tool, and professional judgment in collaboration with the Primary Care Manager and entire healthcare team. Collaborates and coordinates with healthcare professionals/departments to identify members needing additional education or clinical management of selected diseases. Collaborates with case manager, utilization manager, and Managed Care Support Contractor to identify patients appropriate for each service, and to provide assistance with outcome tracking. Works collaboratively with Referral Management Center. Works in alliance with the Quality Management Department to deliver “best value” healthcare that is performance based. Conducts special studies as indicated by outcome measurements and in conjunction with other aspects of the Quality Improvement /Risk Management Programs Orients healthcare teams to the purpose of the disease management activity, population health, clinical preventive services, and medical management. Excellent oral communication skills for patient/family education and telephone triage of patients. Telephone and in-person assessment/evaluation includes the determination of the optimal time and location for patient management (ER, clinic, homecare) and follow up as required. Prescribes and communicates treatment plans and patient teaching in accordance with established clinical protocols approved by the Executive Committee of the Medical Staff. Collects and assesses significant patient history information and performs all necessary teaching. Excellent written communication skills to perform accurate documentation, both written and electronic, of all activity, including telephone contacts, in accordance with requirements of peer review standards. Provides OJT and in-service education to professional, paraprofessional, and ancillary staff to advance their knowledge base and/or skill level. Participates in, completes, and documents professional Continuing Nursing Education (CNE) to comply with licensure and Air Force requirements, MTF initial and annual training requirements, and required unit-specific in- services/training. Participates in evaluation of the quality and effectiveness of activities and services of the unit by organizing, monitoring, and evaluating nursing activities. May be required to augment clinical nursing support during absence of primary care team nurses per AFI 44-171, section 2.2.4.4. As a clinical nurse augmented, assesses, and identifies individual patient care needs and provides the type and amount of care required to meet the individual needs of each patient, making independent nursing diagnoses, providing health care instructions and/or appropriate referral to a physician or other department. In addition, performs clinical or diagnostic procedures which may include catheterizations, visual acuity tests, blood glucose monitoring, pulmonary function testing, cardiac stress testing, Electrocardiograms (ECGs), tonometry, oxygen and nebulization therapy, intravenous fluid therapy, wound care, irrigation of eyes and ears, etc., in accordance with established procedures. Reviews patient record prior to appointment, to include Preventive Health Assessment and Individual Medical Readiness/Personal Health Assessment (PIMR/PHA) deficiency, preventive health needs, completion of referrals, medication refill/renewal requirements, and lab/radiology studies as needed. Assists providers with patient examinations, therapeutic measures, and procedures, and ensures infection control standards are adhered to. Accurately performs and evaluates procedures (including medications, immunizations, and intravenous therapy) almost all of the time, IAW established Air Force and local guidelines or policies and evidence-based practices. Observes patients’ vital signs such as blood pressure, pulse, respirations, temperature, pulse oximetry, weight, etc. Ensures thorough documentation of nursing care, following Air Force policies/instructions. Must complete Disease Management Course, AF Medical Home Course, Access Improvement Seminar and Diabetes Champion Course within one year of hire at contractor’s expense. Position may require travel away from normal duty area one to two times per year at contractor’s expense.

Requirements

Baccalaureate of Science in Nursing degree or other population health-related fields from an accredited educational institution is required.
BLS is required. The HCW shall hold and maintain Basic Life Support -BLS is required. Certification must be through American Red Cross guidelines. Members must present proof of current certification(s) through American Red Cross to be presented on first day of work. Computer-based training does not constitute fulfilling the training requirements. Must maintain currency at NO cost to the government. Recertification is NOT provided by the MTF. Credential may not lapse for any period of time.
Minimum of five years of experience as registered nurse with at least 12 months of experience in disease management within the last 24 months
Computer skills in data management, Microsoft Office Suite: Outlook, Word, Excel (pivot tables,
Certification in disease-management related area such as: Chronic Care Professional (CCP) by Health Sciences Institute or Certified Health Coach (CHC) by National Society of Health Coaches; or a patient education body such as: Certified Diabetes Educator (CDE) by National Certification Board for Diabetes Educators or Certified Asthma Educator (AE-C) by National Asthma Educator Certification Board; -OR- can be certification eligible with 2 years for BSN of full-time disease management experience. Certification must be obtained within 1 year of starting contract.
For positions involving patient care, candidates must have a permanent, full, and unrestricted Registered Nursing license to practice nursing in a State, District of Columbia, the Commonwealth of Puerto Rico, or a territory of the United States.

Nice To Haves

Advanced degree in a health care discipline is highly desirable, a masters in community health is desirable.
National certification in a related field (e.g. community health, ambulatory nursing, or occupational health, etc.) is recommended.
Strong background in inpatient and outpatient nursing specialties, ambulatory care nursing, prevention, health promotion, disease/condition management, case management, discharge planning, and clinical data analysis highly desirable.
Experience in case management, condition management, discharge planning, utilization management, Telehealth, and performance improvement is preferred.
Power Point, Publisher, and Access are desirable.

Responsibilities

Develops innovative, and/or unique treatment programs to best provide advanced level, specialized, and comprehensive professional nursing care to high- and low-risk patients with diseases/conditions across the healthcare continuum appropriate for disease management interventions.
Prioritizes patients in the disease management program.
Assesses and identifies individual patient care needs and provides the type and amount of care required to meet the individual needs of each patient, making independent nursing diagnoses, providing health care instructions and/or appropriate referral to a provider or other department.
Performs proactive patient management and education.
Supports the provider/patient relationship and plan of care, emphasizes prevention of exacerbations and complications utilizing evidence based practice guidelines and patient empowerment strategies.
Empowers and prepares patients to manage their health and become active participants to meet their healthcare needs.
Organizes internal and community resources to provide ongoing self management support to patients.
Utilizes proven programs to provide health information, emotional support, and strategies for living with chronic illness.
Collaborates with providers and patients to define problems, set priorities, establish goals, create treatment plans and implement solutions.
Interprets and evaluates data appropriately in collaboration with Health Care Integrator and Group Practice Manager.
Provides highly specialized, comprehensive primary, secondary, and tertiary prevention/intervention nursing services to active duty/reserve/retired military members and their families.
Assesses, plans, develops, coordinates, implements, and evaluates preventive and clinical services for all assigned beneficiaries
Initiates and coordinates referrals to other healthcare providers, services, or agencies.
Collaborates with military, base, community and civilian agencies, and TRICARE to ensure coordination of services and continuity of care.
Makes necessary judgments to safely administer immunizations/medications based on knowledge of their effects on the physiological processes and current conditions of the patient.
Administers medications and immunizations via multiple routes, as appropriate.
Coordinates mail-order prescription requests.
Ensures compliance with professional standards of care and practice
Prepares health program maintenance, submission of reports, and assists in writing clinic policies and procedures as assigned.
Participates in Quality Improvement and Risk Management activities.
Utilizes evidence-based research in daily practice.
Applies community and population health management principles and processes.
Identifies candidates for disease management using the Military Healthcare System Population Health Portal, Integrated Clinical Database, Complex Patient Management Tool, and professional judgment in collaboration with the Primary Care Manager and entire healthcare team.
Collaborates and coordinates with healthcare professionals/departments to identify members needing additional education or clinical management of selected diseases.
Collaborates with case manager, utilization manager, and Managed Care Support Contractor to identify patients appropriate for each service, and to provide assistance with outcome tracking.
Works collaboratively with Referral Management Center.
Works in alliance with the Quality Management Department to deliver “best value” healthcare that is performance based.
Conducts special studies as indicated by outcome measurements and in conjunction with other aspects of the Quality Improvement /Risk Management Programs
Orients healthcare teams to the purpose of the disease management activity, population health, clinical preventive services, and medical management.
Telephone and in-person assessment/evaluation includes the determination of the optimal time and location for patient management (ER, clinic, homecare) and follow up as required.
Prescribes and communicates treatment plans and patient teaching in accordance with established clinical protocols approved by the Executive Committee of the Medical Staff.
Collects and assesses significant patient history information and performs all necessary teaching.
Provides OJT and in-service education to professional, paraprofessional, and ancillary staff to advance their knowledge base and/or skill level.
Participates in, completes, and documents professional Continuing Nursing Education (CNE) to comply with licensure and Air Force requirements, MTF initial and annual training requirements, and required unit-specific in- services/training.
Participates in evaluation of the quality and effectiveness of activities and services of the unit by organizing, monitoring, and evaluating nursing activities.
May be required to augment clinical nursing support during absence of primary care team nurses per AFI 44-171, section 2.2.4.4.
Reviews patient record prior to appointment, to include Preventive Health Assessment and Individual Medical Readiness/Personal Health Assessment (PIMR/PHA) deficiency, preventive health needs, completion of referrals, medication refill/renewal requirements, and lab/radiology studies as needed.
Assists providers with patient examinations, therapeutic measures, and procedures, and ensures infection control standards are adhered to.
Accurately performs and evaluates procedures (including medications, immunizations, and intravenous therapy) almost all of the time, IAW established Air Force and local guidelines or policies and evidence-based practices.
Observes patients’ vital signs such as blood pressure, pulse, respirations, temperature, pulse oximetry, weight, etc.
Ensures thorough documentation of nursing care, following Air Force policies/instructions.