Position Title: Registered Nurse (RN) Case Manager

Division: AA

Location: Okinawa, Japan

Position Summary

Advancia Aeronautics is committed to placing people first as we accelerate healthcare delivery and provide superior health readiness for military and federal communities across the globe. We are seeking a Registered Nurse (RN) Case Manager for a long-term contract providing personal medical services to support the Department of Defense (DoD) at U.S. Naval Hospital Okinawa, its Associated Branch Health Clinics, and the U.S. Naval Dental Center Okinawa (3rd Dental Battalion) in Okinawa, Japan.

As a part of the Advancia Aeronautics Team, healthcare workers (HCW) 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.

Essential Duties & Responsibilities

· Participate in all phases of the Case Management Program (CMP) and ensure that the CMP meets established case management (CM) standards of care. Assist in coordinating a multidisciplinary team to meet the health care needs, including medical and/or psychosocial management, of specified patients.

· Case Managers will assess, plan, coordinate, and advocate for services to meet the comprehensive health needs of individuals and families. They will utilize effective communication and available resources to ensure safe, quality, and cost-effective care.

· Serve as consultant to all disciplines regarding CM issues. Provide nursing expertise about the CM process, including assessment, planning, implementation, coordination, and monitoring. Identify opportunities for CM and identify and integrate local CM processes.

· Assist in developing and implementing local strategies using inpatient, outpatient, onsite and telephonic CM; assist in developing and implementing policies and protocols for outcome measures.

· Assist in developing and implementing tools to support case management, such as those used for patient identification and patient

assessment, clinical practice guidelines, algorithms, CM software, databases for community resources, etc.

· Integrate CM and utilization management (UM) and integrate nursing case management with social work case management. Prepare routine reports and conduct analyses.

· Assist in establishing and maintaining liaison with appropriate community agencies and organizations, the Defense Health Agency (DHA), and the Managed Care Support Contractor.

· Maintain adherence to Joint Commission, Utilization Review Accreditation Commission (URAC), Case Management Society of America (CMSA), Defense Health Agency, and other regulatory requirements. Apply medical care criteria (e.g., InterQual).

· Assist with collecting and analyzing baseline data and ongoing outcomes to support continuous quality and cost-effective improvement. Identify gaps in existing services and assists in the development and implementation of appropriate services in a timely and cost-effective manner based on extensive knowledge of case management principles and established standards of care. Trend variances and address them to support continuous quality improvement.

· Provide input on MTF CM resources and make recommendations to the Command as to how those resources can best be utilized.

· Collaborate with the multidisciplinary team members to set patient-specific goals. Develop treatment plans including preventive, therapeutic, rehabilitative, psychosocial, and clinical interventions to ensure continuity of care toward the goal of optimal wellness.

· Work in conjunction with the entire healthcare team and other departments to identify high-risk and/or high-utilizer populations to include, but not limited to, those beneficiaries with multiple providers, multiple admissions/readmissions, Emergency Department visits, catastrophic illness, chronic or terminal illness, and multiple medical problems/dual diagnoses.

· Identify and select clients who can most benefit from case management services available in a particular practice setting.

· Establish and implement mechanisms to ensure proper implementation of patient treatment plan and follow-up post discharge in ambulatory and community health care settings.

· Provide case management advice and consultation.

· Collaborate with other members of the healthcare team, the patient and/ family/support system on a regular basis to establish and update the case management plan of care using evidence-based guidelines (when available and/or applicable).

· Identify measurable short-and long-term goals/outcomes of care with matching strategies to achieve optimal wellness and autonomy (self- management). Incorporate the patient’s cultural background, values and beliefs, readiness to learn and healthcare needs across the continuum of care into the plan.

· Provide the patient/ family with the knowledge and skills necessary for the implementation of the established plan. Facilitate patient and family decision-making activities by keeping them well informed of their rights, responsibilities and options. When indicated, follow patients through hospitalization and follows up in ambulatory and community health care settings.

· Actively measure the patient’s response to the evidence-based plan of care and provide documentation that the plan and the quality of the services offered to the patient correspond to the identified needs.

· Ensure appropriate health care instruction to patient and/or caregivers based on identified learning needs.

· Facilitate multidisciplinary discharge planning and other professional staff meetings as indicated for complex patient cases and develop a database and knowledge of local community resources.

· Assist in developing and implementing mechanisms to evaluate the patient, family and provider satisfaction and use of resources and services in a quality-conscious, cost- effective manner.

· Close cases when goals are met, patient declines service, patient transitions to another case manager or patient needs are no longer identified.

· Provide case management orientation and education for other case managers new to the role and/or facility providing scientific and practice-based knowledge per the Case Manager Core Competencies.

· Provide support to other case managers, including managing caseloads during absences.

· Facilitate and coordinate strategies to ensure smooth transition and continued health care treatment for patients when the military member transfers out of the area. Develop a policy for, and assist with, region- to-region transfers. This shall include coordination of required tests, procedures, treatments, discharge planning, community referrals, and transfers.

· Facilitate screening and assist with transfers of Exceptional Family Member Program (EFMP) families and service members going through the Integrated Disability and Evaluation System (IDES).

· Participate in video teleconferences (VTCs) and other meetings as required.

· Provide safe, quality clinical case management services to a variety of eligible beneficiaries, in accordance with the DHA, Department of Defense (DoD), BUMED, Regional, directorate, and departmental instructions, policies and procedures.

· Keep informed of research and new information that will ensure new methods and practices are incorporated into the case management program; attends continuing education programs, seminars, and conferences in order to maintain core competencies in case management.

· Facilitate command cost containment through proper utilization of available resources and timely assessment of patient response to the case management program.

· Assist in the design, implementation, sustainment and ongoing improvement of the case management program.

· Increase MTF staff involvement in, and support of, case management initiatives by providing orientation and ongoing education and in-service training specific to case management and the program.

· Coordinate a warm hand-off between the MTF, the case manager, and the Department of Veterans Affairs (VA) case manager for all Service members transferring to the VA system or to other MTF’s, and civilian care facilities.

· Enhance continuity of care and decrease fragmentation by providing education, developing strategies, and intervening when required to restore or maintain optimal health.

· Plan for professional growth and development as related to the case manager position and maintenance of CM certification.

· Participate in creating and routing patient packages that need further review within MTF.

· Expectation is for the case manager to appropriately manage 50 or fewer cases. Evaluation of the number of cases to be managed by each CM can be modified by the CM supervisor or higher authority.

· Evaluate effectiveness of self-care given by all health team members, and condition of system, environment, and instrumentation in progressing patient toward outcomes.

· Seek validation of knowledge base, skill level, and decision making as necessary and assertively seek guidance in areas of question.

· If directed, perform phone triage based on accepted protocols and assist as needed in accessing appropriate ambulatory/emergency care for beneficiaries.

· Formulate and use effective working relationship 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.

· Performance Improvement/Quality Assurance:

The HCW shall:

· Participate with their supervisor in departmental and hospital performance improvement activities/risk management programs as prescribed and make recommendations on improvement of work methods and organizational features.

· Participate in staff quality assurance functions to include peer review and clinic performance improvement. Attend and contribute to scheduled meetings to review and evaluate the care provided to patients, identify opportunities to improve the care delivered, and recommend corrective action when problems exist.

·Metrics for Case Management:

· Case Managers will respond to patient-initiated messages within one business day.

· A complete and full health and psychosocial assessment is documented and completed within 3 business days of accepting the patient into CM. If unable to meet this metric, reasoning should be clearly documented within EMR.

· Case Managers will generate, complete an assessment, and sign the encounter for each patient contact within 72 hours. All entries should be accurate, relevant, timely, and complete.

· At least once per 30 calendar days, Case Managers must complete an encounter note for all patients continuing CM services.

· Case Managers are required to document all care provided in the patient electronic health record and close the encounter within 72 hours.

· Case Managers will participate in monthly peer reviews with 90% accuracy.

· Conduct patient assessments weekly from those identified in the screening registry; The Case Manager will evaluate and document the disposition for newly added cases within five business days from the time they appear on the CM Registry.

· The Case Manager is responsible for tracking all their assigned patients accepted for case management services/episodic care services. Case Manager is responsible to maintain, and update assigned trackers daily.

· Case Managers will complete required department & DHA onboarding requirements within 45 days of start date.

Education & Experience Requirements

· Possess a Baccalaureate Degree in Nursing.

· Possess and maintain a current unrestricted license to practice as a registered nurse in any one (1) of the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, or the U.S. Virgin Islands.

· Be a graduate of a school of nursing accredited by the Accreditation Commission for Education in Nursing (ACEN), formerly known as the National League for Nursing Accrediting Commission (NLNAC), or the Commission on Collegiate Nursing Education (CCNE) that conferred a nursing baccalaureate or an advanced nursing degree and possess a minimum of six (6) months of case management experience within the preceding thirty-six (36) months.

· Possess a minimum of two years full-time experience as a Registered Nurse in a primary care setting.

· Possess the necessary knowledge, skills, aptitude, and computer literacy to evaluate, interpret, utilize and apply medical care criteria, such as InterQual, Milliman & Robertson Care Guidelines, Predictive Modeling and Integrated Medical Management Techniques in performance of the task requirements.

· Provide two letters of recommendation written within the preceding two years from practicing providers, supervisors or program administrators attesting to the HCW’s professional skills, competencies, patient rapport, training abilities, etc. Recommendation letters must include; name, title, phone number, date of recommendation, address and signature of the individual providing the recommendation.

· Obtain and maintain a National Provider Identifier (NPI).

· Posses and maintain Basic Life Support (BLS) Certification.

Working Conditions/Working Environment/Physical Demands

· The HCW shall provide services Monday through Friday between the hours of 0600 and 1800. The HCW shall be assigned an 8 to 12 hour shift, (to include an uncompensated .5 to 1 hour meal break depending on shift length). In no instance will the HCW be required to provide services in excess of 80 hours per 2-week period. The specific schedule for each HCW for each 2-week period will be scheduled 1 month in advance by the supervisor.

· Must be proficient in basic computer skills and read, write and speak English to effectively communicate.

· Must be a United States citizen, successfully pass an extensive government background investigation and receive government client approval Work is primarily performed indoors at a Military Treatment Facility; employee shall be physically capable of standing and/or sitting for extended periods of time, have the physical ability to perform assigned tasks, able to lift twenty (20) pounds.

Advancia Aeronautics, LLC is an equal opportunity employer. Advancia Aeronautics LLC does not discriminate in employment opportunities or practices on the basis of race, color, religion, sex, national origin, age, disability, marital status or any other characteristic protected by law.