Registered Nurse Disease Management – 87th Medical Group, McGuire-Dix-Lakehurst, New Jersey

Coordinate patient care in collaboration with a wide array of healthcare professionals. Facilitate the achievement of optimal outcomes in relation to clinical care, quality and cost effectiveness.

Specific tasks include:

  • 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 the matches 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.
  • Completes 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.
  • Demonstrates 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.
  • Performs/assists 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.
  • 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.
  • 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; tele-health; 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.

Qualifications:

  • Must possess a Bachelor of Science in Nursing and graduate from a college or university accredited by National League for Nursing Accrediting Commission (NLNAC), or The Commission on Collegiate Nursing Education (CCNE).
  • Must possess one year of experience in nursing, and disease management.
  • Must possess a current BLS.
  • Must possess a current/active and unrestricted RN license.
  • Must have skills in close reading and comprehension and must be able to complete assignments. independently, using sound judgment in applying broad guidelines to specific cases.
  • Must have the ability to organize casework and present information and ideas in clear and concise terms.
  • Excellent organizational skills, attention to detail, and sound skills in written and oral communication is a must.
  • Must be able to read and speak fluent English
  • Must be able to pass a Federal background check

Leading Solutions is committed to hiring and retaining a diverse workforce. We are proud to be an Equal Opportunity Employer. We are committed to ensuring a workplace free of discrimination based on race, color, religion, age, disability, genetic information, sex, sexual orientation, gender identity, or national origin, military or veteran status, and any other basis protected by applicable law.

Leading Solutions is a Service-Disabled Veteran-Owned Small Business (SDVOSB) and Woman-Owned Small Business (WOSB) headquartered in Kissimmee, Florida. The Company provides professional, technical, administrative, and healthcare services to Government and commercial clients. Leading Solutions customer- centric foundation ensures that our leadership and employees meet customer challenges and build trusting partnerships that lay the groundwork for success.

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