RN Case Managers
Naval Health Clinic Hawaii
Duties: The duties for the HCW are as follows:
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Case Management may require at least one site visit within 30 days of beginning case management services to assess the family situation and facilitate development of a plan.
- Participate in multidisciplinary discharge planning (as required via Tripler Army Medical Center) and other professional staff meetings as indicated for complex patient cases and develop a database and knowledge of local community resources.
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Establish a TRICARE Online (TOL) account and be trained to use the Enterprise-Wide Referral and Authorization System (EWRAS) in the performance of duties or new systems used by the MTF to perform duties.
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Maintain adherence to Joint Commission, URAC, Case Management Society of America (CMSA), and other regulatory requirements. Apply medical care criteria (e.g., InterQual).
- Make recommendations on MTF RN Case Manager resources and utilization.
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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.
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Provide case management advice and consultation.
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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).
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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.
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Provide the patient/ family with the knowledge and skills necessary for the implementation of the established plan.
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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.
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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.
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Ensure appropriate health care instruction to patient and/or caregivers based on identified learning needs.
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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.
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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.
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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.
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Close cases when goals are met, patient declines service, patient transitions to another case manager or patient needs are no longer identified.
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Provide case management orientation and education for other case managers new to the role and/or facility providing scientific and practice-based knowledge per the Case Manager Core Competencies.
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Provide support to other case managers, including managing caseloads during absences.
- 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.
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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).
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Plan for professional growth and development as related to the case manager position and maintenance of CM certification.
- Actively participate in professional organizations including participation in at least one annual national CM conference to be funded by the government to be scheduled at the convenience of the government and the HCW.
- Ensure all training completion documentation is submitted to the region and HQ, as required.
- Participate in video teleconferences (VTCs) and other meetings as required.
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Provide safe, quality clinical case management services to a variety of eligible beneficiaries, in accordance with the Department of Defense (DoD), BUMED, Regional, directorate, and departmental instructions, policies and procedures.
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Keep informed of research and new information that will ensure new methods and practices are incorporated into the case management program; attends continuing education programs, seminars, and conferences to maintain core competencies in case management.
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Facilitate command cost containment through proper utilization of available resources and timely assessment of patient response to the case management program.
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Assist in the design, implementation, sustainment, and ongoing improvement of the case management program.
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Increase MTF staff involvement in and support of case management initiatives by providing orientation and ongoing education and in-service training specific to case management and the program.
Qualifications:
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Degree/Education: Possess a Baccalaureate Degree in Nursing, a Graduate Diploma in Nursing, or an associate degree in nursing, from an accredited agency such as the Accreditation Commission for Education in Nursing (ACEN) or the Commission on Collegiate Nursing Education (CCNE)
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Certifications: Basic Life Support
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Experience: Possess a minimum of 1 year outpatient experience as an ambulatory care nurse within the last 2 years, with experience providing services in psychiatric nursing, behavioral health and/or wellness counseling.
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Licensure/Registration: Possess and maintain a current unrestricted license to practice as a registered nurse in any of the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, or the U.S. Virgin Islands.
