Disease Manager Registered Nurse - FT - Maxwell AFB

Disease Manager Registered Nurse US - AL - Maxwell AFB Overview ServeFed is seeking a full time Disease Manager RN in support of Maxwell AFB, Montgomery, AL.
Seize the Opportunity! At ServeFed, we’re committed to connecting great talent with our exceptional client base.
We hire professionals who bring passion, innovation, and expertise to their work in healthcare, IT, accounting, finance, health and safety, and workforce management.
Join our talent community today and build a rewarding career.
Excellent Compensation & Comprehensive Benefits Paid Vacation, Paid Sick Paid Federal Holidays Medical/Dental/Vision Benefits Company Paid Short-Term Disability, Long-Term Disability, Accidental Death & Dismemberment & Life Insurance 401(k) and future qualification of matching Health and Welfare Benefit About ServeFed: ServeFed is a recognized leader in strategic healthcare staffing and program management solutions.
Since our inception in 2012, we have built a reputation for providing staffing solutions that can be relied upon to make Federal Government agencies and private sector companies more efficient and productive.
We partner with our customers to bridge staffing and programmatic gaps - from contingent and permanent staffing to project consulting and contract management of outsourced medical programs.
ServeFed offers solutions that are scalable, flexible, and cost-effective.
With our knowledge and expertise, we deliver staffing and program management results that drive organizational success.
Responsibilities Job Specific Details and Tasks: The duties include, but are not limited to the following: Coordinate patient care through a continuum and facilitates the achievement of optimal in relation to clinical care, quality and cost effectiveness Identify and stratify individual patients and populations of patients across the spectrum of care at risk for chronic diseases and co-morbid conditions, and evaluate the incidence of such conditions from a variety of established data bases and facility treatment team referrals Facilitate identification, adoption, implementation, and utilization of standardized clinical practice guidelines and protocols for management of specific diseases/conditions Identify, develop, and execute appropriate disease management activities and interventions such as, but not limited to, individual and/or group patient contacts and training classes Conduct a thorough evaluation of the patient’s current physical, psychosocial and health status Document treatment plans, and match the level of patient's care to clinical risk, readiness to change and health literacy Educate/train team and facility staff on policies and procedures for utilization of guidelines, protocols and other disease management activities Foster collaboration and facilitates disease management activities with the patient care team Identify, collect, interpret, and evaluate measurable outcomes of care within established time frames (i.
e.
, quality of services, cost and cost savings, disease management and improvement) Conduct special studies as indicated based on outcomes and other Quality Management/Risk Management and Population Health programs and indicators Proactively coordinate with the Case Manager and Utilization Manager as needed Assist 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 Recognize adverse signs and symptoms and quickly reacts in emergency situations Complete 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 Prescribe and communicate treatment plan and patient teaching in accordance with established protocols Collect and assess significant patient history information and perform all necessary patient teaching Demonstrate skill in setting up, operating and monitoring specialized medical equipment such as cardiac monitoring devices, EKG units, oxygen analyzers, nebulizers, and other clinic specific equipment Perform/assist with procedures such as medication administration, oxygen administration, bladder catheterizations, visual acuity tests, EKGs, irrigation of eyes and ears, tympanograms, splinting, phlebotomy and other clinic specific procedures, in accordance with established protocols Perform assigned duties and tasks in the execution of services to include, but is not limited to: Nursing assessment Planning Implementation and evaluation of care Tele-health Medication administration Clinical nursing procedures Patient education Coordinate and participate in interdisciplinary team meetings, designated facility meetings, and Care Coordination meetings Share knowledge and experiences gained from own clinical nursing practice and education relevant to nursing and disease management Participate in the orientation, education and training of other staff; may participate in committees, work groups, and task forces at the facility Complete medical record documentation and designated tracking logs and data reporting as required by local MTF/AF/DoD instructions, policies and guidance Establish liaisons with case managers; coordinate services through the continuum of care for complex patients Qualifications Minimum Qualifications: Education: Must have graduated with a Bachelor's Degree in Nursing Experience: Minimum of 3 years of experience as an RN, with at least 12 months of experience in management of patient populations with prevalent and chronic disease or related clinical area Familiarity with Department of Defense (DoD), Federal, State, non-profit healthcare systems and organizations, to include DoD Tri-Service Military Healthcare Systems, TRICARE purchased care system, Medicare, Medicaid and the Veterans Administration (VA) is desired License: Must have and maintain an unrestricted license as an RN Certification: Must be certified in disease-management related area such as: Chronic Care Professional (CCP) by Health Sciences Institute or Certified Health Coach (CHC) by National Society of Health Coaches; or a patient education body such as: Certified Diabetes Educator (CDE) by National Certification Board for Diabetes Educators or Certified Asthma Educator (AE-C) by National Asthma Educator Certification Board or a related field (e.
g.
, medical surgical, pediatrics, ambulatory care, nursing administration, etc.
) is highly recommended; OR- can be certification eligible with 3 years for ADN or 2 years for BSN of full-time disease management experience.