Job Specific Details and Tasks: The duties include but are not limited to the following:
• Assess and proactively evaluate patients for discharge planning/case management within 24 hours of identification or notification or, by the close of the first business day after a weekend or holiday. Conduct a systematic, ongoing, and thorough collection of the patient's physical, emotional, psychological, social, and medical status and information via direct patient contact, family/caregiver, and other relevant sources such as professional and nonprofessional caregivers. Review the patient's medical record against McKesson (InterQual) discharge planning criteria to determine readiness for discharge.
• Plan and develop an appropriate patient-specific discharge plan of care within five working days of discharge. Shall coordinate, collaborate, and obtain approval of the plan among the patient, family/caregiver, primary provider, and other members of the healthcare team. Document the review of the plan in the patient's medical record. Shall develop a proactive process for patients undergoing same-day surgeries, anticipating actual and potential needs for post-operative services.
• Implement, coordinate, and execute the discharge plan with the patient and family/caregiver, optimizing access to appropriate services. Shall ensure necessary referrals are ordered by the appropriate discipline and coordinated. Serves as an advocate for, and ensures education is provided to, the patient and family/caregiver as required. Shall promote adherence to the discharge plan for improved healthcare outcomes.
• Ensure coordination of care delivery processes, to include alternate healthcare settings and the home environment, for the purposes of enhancing the patient's health and wellness, safety, productivity, and quality of life, and for providing the most beneficial, cost-effective health care. Shall develop, utilize, and maintain a variety of military and community resources to optimize access to services and medical care. Shall ensure timely and appropriate provision of services.
• Re-evaluate the patient and the plan every 72 hours until discharged per McKesson (InterQual) guidelines, aligning the plan with TRICARE benefits and policies documents in accordance with existing local facility/AF/DoD and other agency guidelines. Shall maintain data collection in accordance with local facility/AF/DoD and other specified agency guidelines. Such data includes but is not limited to resource utilization and patient outcomes, Length of Stay (LOS), and Avoidable Bed Days, analyzing for variance, appropriate interventions and cost containment.
• Conduct timeliness in completion of the discharge plan, patient's adherence and response to the plan, identification of variances, patterns or trends from established practice guidelines and/or standards, established outcome measurements, results of interventions, treatment delivery and timeliness of care, and utilization of resources. Monitors and evaluates the facility's discharge planning program per local facility/AF/DoD policies and guidelines.
• Maintain a level of productivity and quality consistent with the complexity of the assignment, facility policies and guidelines, established principles, ethics and standards of practice of professional nursing, the 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. Shall also comply with the Equal Employment Opportunity (EEO) Program, infection control and safety policies and procedures and follow applicable local facility/AF/DoD instructions, policies, and guidelines.
• Demonstrate knowledge and experience in Patient Advocacy, Patient Privacy, and Customer Relation. Respect and maintain the basic rights of patients, demonstrating concern for personal dignity and human relationships. Only release medical information obtained during the course of this contract to other MTF staff involved in the care and treatment of that individual patient.
• Serve and participate in committees, functions, and other meetings as directed. Shall provide relevant and timely information to these groups and assist with decision-making and process improvement. Shall participate in customer service initiatives, quality projects, and medical readiness activities designed to enhance health services.
• Participate in clinic quality assurance programs to meet standards for the Joint Commission, in QA/RM activities to the extent required by AFI 44-119, Chapters 3, 6 and 8, and the individual MTF QA/RM plan or regulation.
• Complete medical record documentation and coding and designated tracking logs and data reporting as required by local facility/AF/DoD instructions, policies, and guidance and complete all required electronic medical record training, facility-specific orientation and training programs, and any AF/DoD mandated training.
• Prepares all documentation to meet or exceed established MTF standards, including documentation for medical records.
Minimum Qualifications:
Degree/Education: Must possess a minimum of an Associate of Science in Nursing degree.
Experience: Must have a minimum of 3 years of experience working as a Registered Nurse (RN), including at least 2 years of experience in case management and/or discharge planning.
Licensure: Must hold an active and unrestricted RN license from any state.
Life Support Certifications: Must possess a Basic Life Support (BLS) certification.
Benefits
Competitive salary and comprehensive benefits package. Generous PTO, sick leave, plus 11 federal holidays. Medical, dental, vision, HSA, and life insurance. Annual CME stipend and license/certification reimbursement. 401(k) matching.
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