Job Details
Job Location
Eglin AFB - Eglin AFB, FL
Description
Registered Nurse-Disease Manager
Eglin AFB FL
Work Schedule: The Registered Nurse-Disease Manager will be on duty for a minimum
of 40 hours per week. Scheduled shifts are normally Monday through Friday between the
hours of 0600-1700. Shifts are for a minimum of 9 hours per day (to include a one hour,
non-paid, lunch break); however schedules may vary to accommodate demand. The
contracted RN - Disease Manager will be scheduled by the MTF for outpatient visits.
Any schedule changes are to be approved by the Functional Requirements Evaluator
Designee and must be submitted to the COR in writing for coordination with the
company.
Duties: The duties for the HCW are as follows:
Coordinates patient care through a continuum and facilitates the achievement of
optimal outcomes in relation to clinical care, quality, and cost effectiveness.
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
training classes.
Conducts a thorough evaluation of the patient’s current physical, psychosocial and
health status. Documents treatment plans and matches the 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.
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.
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. Expected
to attend staff meetings, or meetings required by the Flight Commander.
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; telehealth;
medication administration; clinical nursing procedures and patient education.
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 Telehealth
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.
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.
Comply with standards of care and practice in accordance with all established
policies, procedures, and guidelines used in the medical treatment facility.
Department COR shall monitor contractor employee productivity, monthly
performance reviews, customer and staff comments, government information systems
and records, customer service information, and time sheets.
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.
Must be skilled in analyzing and defining healthcare needs of a defined population
using standardized assessment tools; administrative requirements for proper
documentation of patient’s 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.
The Disease Manager shall possess a good working knowledge of computer
applications/software to include Microsoft Office programs, Microsoft Outlook email
and internet skills. The Disease Manager shall possess ability to use basic computer
skills to enter patient data and extract patients’ information, from a variety of sources
to include Composite Healthcare System CHCS, Armed Forces Health Longitudinal
Technology Application (AHLTA), MHS GENESIS and integrated clinical database
(ICDB). Contractor shall be proficient and independent in data entry within 2 months
of start date.
The Disease Manager may need to attend AFMS training in order to remain current
with DHA policy and program rules. This may require face-to-face attendance at an
out-of-state location (location TBD) for intensive program updates. Additionally, the
Disease Manager may need to schedule/perform site visits and training for
outlying/support Medical Management programs that would require travel to/from
those locations in the surrounding areas. Video teleconferencing is largely
unavailable and system requirements don’t allow for consistent abilities to make this
a viable option for training. The Government shall reimburse the contractor for travel
costs in accordance with the travel guidance in the contract MQS Basic Contract
PWS.
Qualifications
Qualifications:
Degree/Education (5.2.4): Hold an Associate Degree in Nursing from a nationally accredited program required. 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.
Certifications : Shall hold current American Heart Association or the American Red Cross Healthcare
Provider (HCP) or Basic Life Support (BLS) certification. Certification granted based solely on computer-based training does not constitute fulfillment of this requirement.
Experience: Shall have at least 4 years of active nursing practice as a Disease Manager or related field.
Licensure/Registration: Current, full, active, and unrestricted license to practice as a Registered Nurse as required in the TO from a United States (US) jurisdiction, state or territory.