**Core Duties:**

The incumbent is responsible for providing comprehensive case management, care coordination, and discharge/disposition planning in both inpatient and outpatient care environments. 

This role involves assisting service members, veterans, their family members, and caregivers in accessing the most appropriate options and services to address their complex healthcare needs. 

Such needs may encompass a range of conditions, including but not limited to acute, chronic, multiple, complex, catastrophic, or life-threatening illnesses; effects of combat stress; residuals of traumatic brain injury; community reintegration challenges; addiction issues; Transgender Care; and other health concerns.

 The individual will coordinate care with various providers across all levels and types of healthcare settings. 

A holistic approach will be taken to address psychosocial, nursing, and medical requirements for patients and their families or caregivers by engaging in a multidisciplinary patient care management practice. Ongoing evaluation of care and outcomes will be conducted to ensure timely and appropriate service delivery.

The role requires expertise in the following core case management functions: a) 

**Assessment**: Identification of patients requiring case management; comprehensive collection of patient information and medical status; and continuous evaluation of the established care plan; 

b) **Planning**: Collaboration with the patient, family members, caregivers, primary providers, and other healthcare team members to develop an effective care plan; 

c) **Facilitation**: Coordination of care and communication among all stakeholders; 

d) **Advocacy**: Support for patients and their families/caregivers to guarantee that identified educational needs and timely, appropriate care are fulfilled.

The candidate must possess a thorough understanding of medical privacy and confidentiality regulations, specifically the Health Insurance Portability and Accountability Act (HIPAA), as well as accreditation standards set forth by the Accreditation Association for Ambulatory Health Care (AAAHC) and The Joint Commission (TJC).

 Proficiency in computer applications and software, including Microsoft Office programs, MS Outlook (email), and general internet navigation, is essential.

The successful applicant must demonstrate effective and tactful communication skills, especially when engaging with individuals who may be physically or mentally ill, uncooperative, fearful, emotionally distressed, or occasionally confrontational. 

The candidate must also exhibit strong organizational, problem-solving, and communication abilities to effectively convey medical requirements to patients, families, caregivers, and both medical and non-medical staff in a professional and courteous manner.

- Participation in all phases of the Case Management Program (CMP) is required to ensure adherence to established case management (CM) standards of care.

- Provision of nursing expertise related to the CM process, including assessment, planning, implementation, coordination, and monitoring is expected. Opportunities for CM must be identified, and local CM processes integrated accordingly.

- The development and implementation of local strategies utilizing inpatient, outpatient, onsite, and telephonic CM are required.

- Development and utilization of tools to support case management, such as those for patient identification and assessment, clinical practice guidelines, algorithms, CM software, and databases for community resources are essential.

- Integration of CM and utilization management (UM), as well as collaboration between nursing case management and social work case management, is necessary.

- Maintaining liaison relationships with relevant community agencies and organizations is expected.

- Accurate collection and documentation of patient care data is imperative.

**Schedule:** Monday to Friday with an 8-hour shift between 7:00 AM and 4:00 PM. 

There are no weekend or holiday obligations.

**Minimum Qualifications:** - 

**Degree:** The applicant must possess either an associate degree in nursing (ADN) or a baccalaureate degree in nursing (BSN). - 

**Education:** Graduation from a nursing program accredited by a recognized national nursing accrediting agency recognized by the United States Department of Education is required. - 

**Experience:** A minimum of three years of experience for ADN holders or two years for BSN holders in clinical case management is required, working with diverse populations including adults, children, families, seniors, and groups. - 

**Certification:** Certification as a Case Manager from either the Commission for Case Management (CCM) or the American Nurses Credentialing Center (ANCC) is required, or the candidate must be certification-eligible with the requisite experience. - 

**Licensure:** The candidate must maintain an active, valid, current, and unrestricted license to practice as a registered nurse in any state or jurisdiction within the United States, without any limitations, stipulations, or pending adverse actions. -

 **Security Clearance:** 

The ability to pass a government background check/security clearance is mandatory. - 

**Life Support Certification:** 

The candidate must possess current certification as a Basic Life Support (BLS) Healthcare Provider from either the American Heart Association (AHA) or the American Red Cross (ARC).