Registered Nurse - Disease Manager

Overview

Goldbelt Glacier is accelerating healthcare delivery and providing superior force health readiness across the military, federal, and civilian landscapes. Goldbelt Glacier is committed to providing transformative and comprehensive health operational capabilities to support customers across scientific, clinical, technological, and program management areas.

Summary:

As a part of the Goldbelt Glacier Team, you will be supporting the Naval Logistics Command with medical services for active-duty military personnel, their dependents, eligible DoD civilian employees, and other eligible beneficiaries designated by the Government. As a HealthCare Worker (HCW), you will be assigned to either a Military Treatment Facility (MTF) or other Federal medical treatment facilities in Japan.

We welcome applications from all qualified candidates; however, individuals currently residing in Japan will receive priority consideration.

Responsibilities

Essential Job Functions:

• Develops and evaluates the annual disease management plan for the inclusion in the population health plan in collaboration with stakeholders (e.g., Chief of Medical Staff, Chief Nurse, Health Care Integrator, Group Practice Manager, medical management team).
• Uses available data sources to identify, assess, and prioritize the needs of a target subset of beneficiaries for specific disease management programs.
• Ensures preventive care is included in the disease management plan of care.
• Proactively 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 approved by the Executive Committee of the Medical Staff.
• Documents disease management related care provided using the ELAD line of accounting medical Expense and Performance Reporting System (MEPRS) code for all face-to-face, telephonic, or MHS GENESIS Patient Portal Messaging interactions. Coding will include current international Classification of Disease (ICD), Evaluation and Management (E&M), and disease management- specific Healthcare Common Procedure Coding System (HCPCS) codes and the encounters must be completed and signed within 3 business days.
• Completes medical record documentation (in MHS Genesis) and/or other AF/DHA approved electronic health care record).
• Will track (via Carepoint) disease management-related data, processes and outcome measures, identified opportunities for improvement, and status of process improvement programs daily. This information will be reported to the Population Health Working Group quarterly.
• Communicates and collaborates as needed with other members of the healthcare team and managed care support contractor’s medical management staff as needed to ensure continuity of care for patients with chronic illness.
• Tracks and reports healthcare outcomes of individual patients with chronic conditions to applicable primary care teams.
• 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); document direct person-to-person summary in the electronic health record.
• Will conduct standardized peer reviews quarterly to evaluate appropriate use of resources, timely assessments and interventions in addition to the adherence of clinical and administrative standards to include appropriate coding practices for workload.
• Develops and executes appropriate multidisciplinary disease management activities in collaboration with the Chief of Medical Staff, Chief Nurse, Health Care Integrator, Medical Management Director, Behavioral health Care Facilitator, Case Manager, Utilization Manager, and primary care teams in support of population health and population health management initiatives.
• Ensures collaborative communication processes exists between the primary care and medical management teams. Collaborates with the Health Care integrator, other medical management staff, and primary/specialty care teams to plan and implement population health strategies.
• Maintains professional manner and displays positive /cooperative attitude. Will respond to referrals within 48 hours. Will answer phone calls immediately or return call within the duty day the call is received
• Assess each patient and perform triage duties as assigned.
• Formulate and carry out a goal directed plan of care which based on determined nursing diagnosis and patient outcomes and which is prioritized according to patient needs and available resources including time, personnel, equipment, and supplies.
• Evaluate effectiveness of self-care given by all health team members, and contribution of systems, environment, and instrumentation in progressing patient toward outcomes.
• Provide treatment and discharge instructions upon patient release.
• Perform assessment/data collection in an ongoing and systematic manner, focusing on physiological, psychological, and cognitive status.
• Provide a safe and clean environment for each patient.
• Identify patient/significant other learning needs and implement appropriate measures to meet identified needs.
• Assist in planning, provide clinical direction, and provide instruction to LPNs/LVNs, nursing assistants and ancillary personnel.
• Demonstrate sound knowledge base and action in the care and decision making for designated patient populations. If weaknesses or deficiencies are identified either by peer reviews, quality control reports (QCRs), or evaluations the HCW will be required to complete refresher training (in-services, competency reviews, continuing education, etc.) at contractor expense.
• Perform documentation (manually and/or by use of computer) duties on unit and in-patient record that are timely, accurate, and concise.
• Implement care in a knowledgeable, skillful, consistent, and continuous manner.
• Establish priorities of patient care based on essential patient needs and available unit, command, and community resources including time, personnel, equipment, and supplies.
• Demonstrate competency in medication and intravenous (IV) administration to include blood products and Total Parental Nutrition (TPN) intramuscular (IM) and subcutaneous (SQ) administration and demonstrate competency in phlebotomy as specific to the position.
• Safely administer prescribed medications to include intravenous drips and intravenous push drugs.
• Identify patient/significant other learning needs and implement appropriate measures to meet identified needs.
• Perform documentation (manually and/or by use of computer) duties on unit and in-patient record which are timely, accurate, and concise.
• Assist with the teaching of formal and informal classes, as directed by the Government Supervisor, to new paraprofessional personnel with the goal of helping them successfully complete competency-based skills list and weekly goal setting, assisting in the
• Command’s Basic Cardiac Life Support classes.
• Demonstrate self-directed learning.
• Assist in development and attainment of unit and Nursing Directorate goals.
• Demonstrate effective and professional communication methods, and skills, using lines of authority appropriately.
• Formulate and use effective working relationships with all health care team members, patients, and significant others. Refer unsolved complaints or infractions to the Division Head with recommendations for appropriate action.
• Practice effective problem identification and resolution skills as a method of sound decision making.
• Remain flexible in staffing patterns and resolution of staffing conflicts; participate in temporary assignment measures.
• Provide individual, group, and family/significant other counseling and health teaching in relation to the patient's condition and his/her ability for self-care. Provide for accessibility to various literature resources dealing with subjects related to specific patient health
• problems. Provide physical and psychological support to patients and significant others, explain procedures and treatments, and promote cooperation among staff, patients, and significant others.
• Assist in the orientation and training of newly assigned unit personnel as directed by Government Supervisor.
• Provide input into competency assessments of newly assigned unit personnel as directed by government supervisor.
• Collaborate in the review of clinic standing operating procedures as directed by government supervisor.
• If directed, perform phone triage based on accepted protocols and assist as needed in accessing appropriate ambulatory/emergency care for beneficiaries.
• Provide training and/or direction as directed by the government supervisor to supporting government employees (i.e. hospital corpsmen, technicians, students) assigned to the HCW during the performance of clinical procedures. Such direction and interaction will adhere to government and professional clinical standards and accepted clinical protocols.

Qualifications

Necessary Skills and Knowledge:

• 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 DMN shall read, understand, speak, and write English fluently.
• Maintain a level of productivity comparable with that of other individuals performing similar services.
• Adhere to and comply with the Department of the Navy, Bureau of Medicine and Surgery, and local instructions and notices in effect during the term of the contract.
• Practice aseptic techniques as necessary; comply with infection control guidelines to include the proper handling, storage, and disposal of infectious wastes, and the use of universal precautions to prevent the spread of infection.
• Function with an awareness and application of safety procedures.
• Apply an awareness of legal issues in all aspects of patient care and strive to manage situations in a reduced risk manner.
• Exercise awareness and sensitivity to patient/significant others' rights, as identified within the MTF.
• Maintain an awareness of responsibility and accountability for own professional practice.
• Maintain DoD email account as directed by government supervisor.
• Exercise appropriate delegation of tasks and duties in the direction and coordination of health care team members, patient care, and clinic activities.
• Each HCW providing service under this contract or resultant task orders shall undergo an orientation and shall complete mandatory Navy and DoD on-line training as required.
• Be able to comply with all applicable Federal, State, and local laws, Department of Defense, Department of Navy, Bureau of Medicine and Surgery, and MTF instructions and policies.
• Proficiency in Microsoft Office software applications including Word, Excel, Access, PowerPoint, and Outlook.

Minimum Qualifications:

• Graduate with a Bachelor's of Science in Nursing (BSN) from a program accredited by a national nursing agency and recognized by the United States Department of Education.
• Must have at least two (2) years of clinical experience in a primary care setting to include; outpatient clinic, inpatient hospital, emergency room or urgent care.
• Possess and maintain a current, valid, and unrestricted license to practice as a registered nurse in any one of the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, Guam or the U.S. Virgin Islands
• HCW shall be in good standing, and under no restrictions, with the state licensure board in any state in which a license is held or has been held within the last 10 years.
• HCW shall be in good standing and under no sanction or suspension by the Federal Government.
• Possess and maintain current certification in either the American Heart Association BLS for Healthcare Providers or American Heart Association Healthcare Provider Course.
• Able to read, write, speak, and understand the English language fluently and maintain good communication skills with patients and other health care personnel.
• Ability to pass all background/suitability checks.
• A valid driver’s license; ability to travel locally as needed.
• Must be a US Citizen.

Preferred Qualifications:

• A thorough understanding of the military lifestyle and experience working with military family members.
  
• Working knowledge of relevant military, state, federal, and local laws and resources.
  
• Highly developed written, oral, and presentation communication skills
• A minimum of 2 years full-time experience as a BSN in management of patient populations with prevalent and chronic diseases is preferred.
• An active security clearance is preferred.

Pay and Benefits
At Goldbelt, we value and reward our team's dedication and hard work. We provide a competitive base salary commensurate with your qualifications and experience. As an employee, you'll enjoy a comprehensive benefits package, including medical, dental, and vision insurance, a 401(k) plan with company matching, tax-deferred savings options, supplementary benefits, paid time off, and professional development opportunities.