**Core Responsibilities:**

The role involves comprehensive case management, care coordination, and discharge planning for both inpatient and outpatient settings. 

The primary focus is on assisting service members, veterans, their families, and caregivers in navigating complex healthcare needs, which may include acute, chronic, multifaceted, catastrophic, or life-threatening conditions, including but not limited to combat stress, residuals of traumatic brain injury, community reintegration, substance use disorders, transgender healthcare, and other health-related issues. 

Coordination of care is essential, requiring collaboration with various providers across diverse care levels and locations. The position entails addressing not only the psychosocial needs but also nursing and medical requirements of patients and their support systems through active participation in a multidisciplinary patient care management approach. Regular evaluation of care and outcomes is necessary to ensure timely and appropriate service delivery.

**Key Functions:**

- Engage fully in all aspects of the Case Management Program (CMP) to ensure adherence to established case management (CM) standards of care.

- Leverage nursing expertise throughout the CM continuum, which includes assessment, planning, implementation, coordination, and monitoring. Actively identify opportunities for improvement within CM processes and integrate local frameworks.

- Formulate and execute strategies utilizing inpatient, outpatient, telephonic, and onsite case management approaches.

- Develop and implement tools to enhance case management efficacy, including patient identification and assessment instruments, clinical practice guidelines, algorithms, CM software, and databases of community resources.

- Forge strong connections with community agencies and organizations to facilitate seamless care transitions. - Ensure accurate collection and documentation of patient care data for informed decision-making and reporting.

**Minimum Qualifications:**

- 

**Academic Credentials:** Candidates must hold an associate degree in nursing (ADN) or a baccalaureate degree in nursing (BSN). - 

**Educational Background:** Graduation from a nursing program accredited by a recognized national nursing accrediting agency as per the US Department of Education standards is required. -

 **Professional Experience:** A minimum of three years of full-time clinical case management experience is required for ADN holders, whereas BSN holders must have at least two years of similar experience, working with diverse populations including adults, children, families, seniors, and groups.   -

 **Certification:** The candidate must be a Certified Case Manager (CCM) by the Commission for Case Management or the American Nurses Credentialing Center (ANCC), or eligible for certification with three years of experience for ADN or two years for BSN in clinical case management.   -

 **Licensure Status:** An active, valid, unrestricted nursing license to practice as a registered nurse in any US state or jurisdiction is mandatory, with no limitations or pending adverse actions.   -

 **Security Clearance:** The ability to successfully pass a Government background check/security clearance is required.   - 

**Life Support Certification:** Current certification in Basic Life Support (BLS) from either the American Heart Association (AHA) or the American Red Cross (ARC) is necessary.