(Archived) Clinical Nurse - Disease Manager

Essential Duties and Responsibilities: (Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position) · Coordinates patient care though a continuum and facilitates the achievement of optimal outcomes in relation to care, quality and cost effectiveness. · Identifies and stratifies individual patients and populations of patients across the spectrum of care at risk for chronic diseases and co-morbid conditions, and evaluates the incidence of such conditions from a variety of established data bases and facility treatment team referrals. · Facilitates identification, adoption, implementation and utilization of standardized clinical practice guidelines and protocols for management of specific diseases/ conditions. · Identifies, develops and executes appropriate disease management activities and interventions such as, but not limited to, individual and/or group patient contacts and training classes. · Conducts a thorough evaluation of the patient’s current physical, psychosocial and health status. Documents treatment plans and the matches level of patient’s care to clinical risk, readiness to change and health literacy. · Educates/trains team/facility staff on policies and procedures for utilization of guidelines, protocols and other disease management activities. Fosters collaboration and facilitates disease management activities with the patient care team. · Identifies, collects, interprets and evaluates measurable outcomes of care within established time frames (i.e., quality of services, cost and cost savings, disease management and 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 and Chief of Medical Staff. Reports disease management efforts to MTF leadership through committees such as Population Health Working Group. · Proactively coordinates with the Case Manager and Utilization Manager as needed. · Assists in development of facility’s Medical Management/Population Health plan in support of the annual Business Plan, ensuring a process for collecting disease management data, monitoring performance, and identifying improvement opportunities. · Recognizes adverse signs and symptoms and quickly reacts in emergency situations. · Completes in-person and telephonic evaluations that include determination of optimal time and location for patient management (i.e., ER, clinic, homecare) and follow-up care as required. Prescribes and communicates treatment plan and patient teaching in accordance with established protocols. Collects and assesses significant patient history information and performs all necessary patient teaching. · Demonstrates skill in setting up, operating and monitoring specialized medical equipment such as cardiac monitoring devices, EKG units, oxygen analyzers, nebulizers, and other clinic specific equipment. · Performs/assists with procedures such as medication administration, oxygen administration, bladder catheterizations, visual acuity tests, EKGs, irrigation of eyes and ears, tympanograms, splinting, phlebotomy and other clinic specific procedures, in accordance with established protocols. · May be required to work an adjusted schedule or augment clinical nursing support during the absence of other team nurses due to illness, leave or deployment. · Performs assigned duties and tasks in the execution of services to include, but is not limited to: nursing assessment, planning, implementation and evaluation of care; tele-health; medication administration; clinical nursing procedures and patient education. · 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 nursing and disease management. · Participates in the orientation, education and training of other staff. May participate in committees, work groups, and task forces at the facility. · Must maintain 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, NHLBI Clinical Practice Guidelines American Diabetes Association, and other evidence-based disease management professional guidelines; telephone triage and other tele-health professional standards and guidelines; Case Management Society of America (CMSA); American Accreditation Healthcare Commission/Utilization Review Accreditation Commission (URAC); CAMH; (AAAHC); Health Services Inspection (HSI); and other applicable DoD and Service specific guidance and policies. Must also comply with the Equal Employment Opportunity (EEO) Program, infection control as well as safety policies and procedures. · Completes medical record documentation and designated tracking logs and data reporting as required by local MTF/AF/DoD instructions, policies and guidance. · Completes all required electronic medical record training, MTF-specific orientation and training programs, and AF/DoD mandated training. · Be able to perform with minimal supervisory direction. Be able to independently identify, plan, and carry out projects with consideration for the goals and objectives of the MTF’s Utilization Management and Medical Management Departments. · Develops detailed procedures and guidelines to supplement established administrative regulations and program guidance. Recommendations are based upon analysis of work observations, review of procedures, and application of guidelines. Minimum Qualifications: (To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.) · Must have a Baccalaureate of Science in Nursing degree. Program must be accredited by a national nursing accrediting agency recognized by the US Department of Education. · A minimum of Six (6) years of broad-based clinical nursing experience is required with three years of progressively increasing managed care responsibilities with a focus in Disease Management. · Experience with disease management, clinical practice guidelines, performance improvement, and personnel management required. · Full time employment in a nursing field for at least 12 of the last 18 months is mandatory. · 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. Certification is mandatory; candidate must have at least one of these certifications. · 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. · Must have a current Basic Life Support (BLS) certification. Chenega Corporation and family of companies is an EOE. Equal Opportunity Employer Minorities/Women/Veterans/Disabled/Sexual Orientation/Gender Identity Native preference under PL 93-638. We participate in the E-Verify Employment Verification Program.