• Participate in all phases of the Case Management Program (CMP) and ensure that the CMP meets established case management (CM) standards of care.
• Maintain adherence to Joint Commission, URAC, Case Management Society of America (CMSA), and other regulatory requirements. Apply medical care criteria (e.G., InterQual).
• Provide nursing expertise about the CM process, including assessment, planning, implementation, coordination, and monitoring.
• Integrate case management (CM) with utilization management (UM) and disease management as needed. Integrate nursing case management with social work case management.
• Develop and implement local strategies using inpatient, outpatient, onsite and telephonic CM
• Develop and implement tools to support case management, such as those used for patient identification and patient assessment, clinical practice guidelines, algorithms, CM software, and databases for community resources.
• Maintain liaison with appropriate community agencies and organizations.
• Provide input on hospital CM resources and make recommendations to the Command as to how those resources can best be utilized.
• 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.
• 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.
• 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.
• 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).
• Keep informed of research and new information that will ensure new methods and practices are incorporated into the case management program.
• Facilitate command cost containment through proper utilization of available resources and timely assessment of patient response to the case management program.
• Perform clinical assessments of the patients and managed care records that include clinical input from various health care providers across all clinical areas.
• Perform follow-up clinical assessments to ensure the effectiveness of treatment plans in place.
• Accurately collect and document patient care data.
• Operate and manipulate automated systems such as CHCS, AHLTA, ADS, Essentris, and Clinical Information System (CIS)

• Degree: Associates Degree of Nursing.
• Education: Graduate from a college or university accredited by Accreditation Commission for Education in Nursing (ACEN), or The Commission on Collegiate Nursing Education (CCNE).
• Possess two years of case management experience within the last three years.
• Certification: Possess one of the following certifications:
  • 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) or Certified Occupational Health Nurse-Specialist (COHN-S).
  • 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
  • Possess a minimum of 2 years full-time experience within the last 3 years as a registered nurse providing case management and obtain one of the eight certifications, above, within six months of hire.
• Current, full, active, and unrestricted license to practice as a Registered Nurse as required in the TO.
• Possess and maintain BLS.
• Must be a U.S. Citizen (for access to Gov't computer systems)

• Competitive pay
• 10 days paid time off per year plus 7 sick days per year
• 10 paid Federal holidays
• Health & Welfare allowance covers the cost of health insurance, long and short-term disability, and life insurance
• Dental and vision plans offered, 401(k)

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

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