RN Disease Manager

Overview

Location: Keesler AFB, MS

Schedule: Duty schedule for personnel will be Compressed Work Schedule which will consist of 9 hour shifts Monday through Thursday between 0600 – 1800 and an 8 hour shift on one Friday between 0600 – 1800 with the alternate Friday off. Shifts will not exceed 9 hours Monday – Thursday and 8 hours on the working Friday and 80 hours in 2 weeks.

All days will include an uncompensated 60 minute lunch break.

Benefits: Vested vacation, sick leave, holiday leave, Life, Accidental Death and Dismemberment, Short Term Disability

Optional Benefits: Medical, Dental, Vision, 401(K) matching with employee participation in 401(K) plan

-Provides comprehensive Disease Management (DM) services, applies and promotes DM, health promotion, and wellness concepts and strategies to assigned patients and those identified for DM.

-Assesses, plans, develops, coordinates, implements, and evaluates preventive and clinical services for all assigned beneficiaries covering comprehensive primary, secondary, and tertiary prevention/intervention across the population health continuum ranging from normal to those having complex complications.

-Implements disease management services for populations with chronic conditions, collaborates with patients in formulating patient-centered goals, and educates individuals and groups based on clinical practice guidelines (CPGs) approved by the Executive Committee of the Medical Staff.

-Proactively collaborates with the patient and healthcare teams, and utilizes evidence based tools, such as predictive analytics, to identify patients who would benefit from disease-specific education and patient-centered care. Conducts a thorough evaluation of the patient’s current physical, psychosocial, and health status. Documents treatment plans and matches the level of patient care to clinical risk, readiness to change, and health literacy. The goal is to promote self-management, prevent or delay the progression of disease, improve clinical and financial outcomes, and advocate appropriate resource utilization.

-Facilitates identification, adoption, implementation and utilization of standardized CPGs and protocols for management of specific diseases and conditions. Educates/trains teams/staff on policies and procedures for the utilization of guidelines, protocols, and other disease management activities.

-Identifies, develops and executes appropriate multidisciplinary disease management activities and interventions in collaboration with the Chief of Medical Staff, Chief Nurse, Health Care Integrator, Medical Management Director, Behavioral Health Care Facilitator, Case Manager, Utilization Manager, Discharge Planner, Group Practice Manager, and primary/specialty care teams in support of population health and population health management initiatives.

-Identifies, collects, interprets, and evaluates measurable outcomes of care within established time frames (e.g., quality of services, cost and cost savings, disease management, and continuous process 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/Medical Management Director and Chief of Medical Staff. Reports disease management-related data, process and outcome measures, identified opportunities for improvement, status of process improvement programs and other requested information to MTF leadership through committees, such as Population Health Working Group. Develops and evaluates the annual disease management plan for inclusion in the population health plan in collaboration with stakeholders.

-Provides a direct person-to-person summary (i.e., verbal communication providing continuity of care and a seamless transfer of information) of patients transitioning to other levels or places of care by providing pertinent information to the receiving healthcare provider (e.g., patient self-management status at graduation from the disease management program to primary care team, or transfer to case management for more sensitive services);

doc…