Registered Nurse - Disease Manager - CentralCare Inc

Registered Nurse- Disease Manager

JOINT BASE SAN ANTONIO (JBSA) - LACKLAND AFB, TEXAS

Degree/Education -Bachelor of Science in Nursing or related field. Graduate from a college or university accredited by National League for Nursing Accrediting Commission (NLNAC), or The Commission on Collegiate Nursing Education (CCNE).

Certifications -Basic Life Support (Current)

Experience: FOUR years’ experience as a Registered Nurse, A minimum of 4 years for BSN full-time experience after graduation in management of patient populations with prevalent and chronic diseases

Board Certification- Licensure/Registration: • Current, full, active, and unrestricted license to practice as a Registered Nurse as required in the TO.

Job Responsibilities-The duties for the HCW are as follows:

• Coordinate patient care in collaboration with a wide array of healthcare professionals. Facilitate the achievement of optimal outcomes in relation to clinical care, quality, and cost effectiveness. 
• Ensure compliance with standards of care and practice in accordance with all established policies, procedures, and guidelines used in the MTF. • Perform health histories. • Provide health promotions, counseling, and education. 
• Administer medications and numerous other personalized interventions.
• Direct and supervise care provide by other healthcare professionals 
• Recognize adverse signs and symptoms and quickly react in emergency situations. 
• Communicate and collaborate with a diverse group of people for the purpose of informing the healthcare team of plans/actions, for teaching/education to benefit the patient/family and organization.
• Make referral appointments and arrange specialty care as appropriate. 
• Perform nursing services identified in the TO.
• Conduct research in support of improved practice and patient outcomes. 
• 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 trainingclasses. 
• 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. 
• 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 andprocedures.
• 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

Pay rate is $40/hr. + H&W: $4.41/hr.=$44.41 Hr.

Holidays: 11 paid

PTO: 80hrs accrued

Sick Leave:  56hrs accrued