Langley AFB , VA - RN Disease Manager

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Langley AFB , VA - RN Disease Manager

SUMMARY: Utilizing major components of population health and disease management, ensures health care interventions for individuals and populations of patients with prevalent and/or chronic diseases in order to achieve disease management compliance, improved overall quality of life, and reduced healthcare costs. Also performs clinical nursing care in the execution of disease management services.


1.1. Must be knowledgeable of clinical and administrative theories, principles, practices, and procedures underlying nursing practice; a wide range of medical disorders/conditions and disease processes across the lifespan to include pediatrics, adolescence, adults, obstetrics, and geriatrics; assessing patients, including the ability to assess/evaluate telephonically; preventive health schedules, procedures, processes and education methods; disease management and population health principles to include primary, secondary and tertiary prevention protocols; a variety of pharmacological agents used in patient treatment, the desired effects, side effects, and complications of their use as well as the accurate administration of the pharmacologic agent, including dosage calculations; computer applications/software to include Microsoft Office programs, MS Outlook (e-mail), and internet; and problem-solving techniques to articulate medical requirements to patients, families/care givers, medical and non-medical staff in a professional and courteous way.

1.2. Must be skilled in analyzing and defining healthcare needs of a defined population using standardized assessment tools; administrative requirements for proper documentation of patientís condition including disease progress, acknowledgement of teaching, and follow up care; communicating with people who may be physically or mentally ill, uncooperative, fearful, emotionally distraught, and occasionally dangerous; applying critical thinking skills and expertise in resolving complicated healthcare, social, interpersonal and financial patient situations.

1.3. 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.

1.4. 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.

1.5. Experience. A minimum of 3 years for ADN/2 years for BSN full-time experience in management of patient populations with prevalent and chronic diseases.

1.6. Certification. 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 3 years for ADN or 2 years for BSN of full-time disease management experience.

2. TYPE OF WORK. The duties include but are not limited to the following:

2.1. Coordinates patient care through a continuum and facilitates the achievement of optimal outcomes in relation to clinical care, quality and cost effectiveness.

2.2. 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.

2.3. Facilitates identification, adoption, implementation and utilization of standardized clinical practice guidelines and protocols for management of specific diseases/ conditions.

2.4. 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.

2.5. Conducts a thorough evaluation of the patientís current physical, psychosocial and health status. Documents treatment plans and the matches level of patientís care to clinical risk, readiness to change and health literacy.

2.6. 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.

2.7. Identifies, collects, interprets and evaluates measureable 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.

2.8. 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.

2.9. Proactively coordinates with the Case Manager and Utilization Manager as needed.

2.10. Assists in development of facilityís 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.

2.11. Recognizes adverse signs and symptoms and quickly reacts in emergency situations.

2.12. 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.

2.13. 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.

2.14. 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.

2.15. 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.

2.16. 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.

2.17. 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.

2.18. Participates in the orientation, education and training of other staff. May participate in committees, work groups, and task forces at the facility.

2.19. 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.

2.20. Completes medical record documentation and designated tracking logs and data reporting as required by local MTF/AF/DoD instructions, policies and guidance.

2.21. Completes all required electronic medical record training, MTF-specific orientation and training programs, and AF/DoD mandated training.

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