SUMMARY: Provides case management, care coordination and discharge/disposition planning for inpatient and outpatient care settings. Assists service members and/or veterans, family members and caregivers with receiving the most appropriate options and services to meet their complex health care needs. This includes, but is not limited to, acute, chronic, multiple, complex, catastrophic, or life-threatening illnesses; combat stress, residuals of traumatic brain injury; community adjustment; addictions and other health problems. Coordinates care with multiple providers across all levels and sites of care. Addresses psychosocial, as well as nursing and medical needs of patients and their families/caregivers, through participation in multidisciplinary patient care management practice. Evaluates care and outcomes to ensure timely and appropriate provision of services.
1.1. Must have the knowledge and skills to effectively apply the following core case management functions: a) Assessment: Identification of patients for case management; comprehensive collection of patient information and medical status; and continued evaluation of an established plan of care; b) Planning: Collaboration with the patient, family/caregiver, primary provider and other members of the health care team for developing an effective plan of care; c) Facilitation: Care coordination and communication among all involved parties; d) Advocacy: Support for the patient and family/caregivers to ensure identified education and appropriate, timely care is received.
1.2. Must be knowledgeable in medical privacy and confidentiality (Health Insurance Portability and Accountability Act [HIPAA]); accreditation standards of Accreditation Association for Ambulatory Health Care (AAAHC) and The Joint Commission (TJC); and computer applications/software to include Microsoft Office programs, MS Outlook (e-mail), and internet familiarity is required.
1.3. Must be skillful and tactful in communicating with people who may be physically or mentally ill, uncooperative, fearful, emotionally distraught, and occasionally dangerous.
1.4. Must possess organization, problem-solving and communication skills to articulate medical requirements to patients, families/care givers, medical and non-medical staff in a professional and courteous way.
1.5. Education. 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.
1.6. License. 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.
1.7. Experience. A minimum of 3 years for ADN or 2 years for BSN full-time experience in clinical case management working with adults, children, families, seniors and groups.