Title Nurse Case Manager

Summary

Flatwater is seeking a dedicated professional to provide case management and care coordination for service members, veterans, and their families. This role focuses on supporting patients with complex health care needs through collaboration with multidisciplinary teams, ensuring access to appropriate resources, and facilitating continuity of care across various settings.

• Provide case management, care coordination, and discharge planning for patients with acute, chronic, complex, or life‑threatening health care needs.
• Collaborate with multidisciplinary teams to address the medical, nursing, and psychosocial needs of patients and their families/caregivers.
• Develop and implement individualized care plans, ensuring effective transitions and continuity of care across inpatient and outpatient settings.
• Assist patients and families in navigating health care systems and accessing appropriate services and resources.
• Evaluate care outcomes to ensure timely, effective, and appropriate provision of services, adjusting plans as needed.
• Facilitate communication between patients, caregivers, and health care providers to optimize health care delivery and outcomes.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Must have the knowledge and skills to effectively apply the following core case management functions.
  • Assessment:
    Identification of patients for case management; comprehensive collection of patient information and medical status; and continued evaluation of an established plan of care.
  • Planning:
    Collaboration with the patient, family/caregiver, primary provider and other members of the health care team for developing an effective plan of care.
  • Facilitation:
    Care coordination and communication among all involved parties.
  • Advocacy:
    Support for the patient and family/caregivers to ensure identified education and appropriate, timely care is received.
• Must be knowledgeable in medical privacy and confidentiality (Health Insurance Portability and Accountability Act [HIPAA]); accreditation standards of Accreditation Association for Ambulatory Health Care (AAAHC) and The Joint Commission (TJC); and computer applications/software to include Microsoft Office programs, MS Outlook (e‑mail), and internet familiarity is required.
• Certified Case Manager by Commission for Case Management (CCM) or American Nurses Credentialing Center (ANCC) –OR– certification eligible with 3 years of experience for ADN or 2 years’ experience for BSN in full time clinical case management with children, families, seniors, or groups.
• Must possess organization, problem‑solving and communication skills to articulate medical requirements to patients, families/care givers, medical and non‑medical staff in a professional and courteous way.
• Strong organizational skills to maintain program file systems and ensure timely responses to communications.
• Ability to use small office equipment, including fax, scanners, and copiers.
• Must be skillful and tactful in communicating with people who may be physically or mentally ill, uncooperative, fearful, emotionally distraught, and occasionally dangerous.

• Associate (ADN) or baccalaureate degree (BSN) program in nursing accredited by a national nursing accrediting agency recognized by the US Department of Education.
• A minimum of 3 years for ADN or 2 years for BSN full‑time experience in clinical case management working with adults, children, families, seniors and groups.
• 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.

This position does not have supervisory responsibilities.

This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.

Native American Owned & Proud | Accountable | Team Focused | Innovative | Visionary | Excellence

The…