Referral/Utilization Management Registered Nurse

Distinctive Home & Health Care is a leading provider of healthcare to serve military installations across the United States. Our team of professionals is dedicated to providing the highest quality of service and support for each one of our clients. Distinctive Healthcare is currently seeking to hire a full-time Referral/Utilization Management Registered Nurse for the Walter Reed National Military Medical Center in Bethesda, Maryland.

Minimum Qualifications

• Nursing Degree
• Active/unrestricted Nursing License
• BLS Certification

Core Duties:

• Provide professional case management services at Walter Reed National Military Medical Center (WRNMMC) or Fort Belvoir Community Hospital (FBCH).
• Function as a member of a multidisciplinary team to meet individual and family comprehensive health needs. Duties involve planning, coordinating, facilitating, and evaluating health care, and serving as an advocate for patient options and services.
• Utilize communication and available resources to promote quality and cost-effective outcomes, across the continuum of care.
• Serves as a clinical case manager and patient advocate, providing advanced practice clinical, administrative, and organizational skills in managing the continuity, access, and provision of care services for complex and defined patients, including catastrophic and end-of-life patient populations.
• Responsible for the identification and management of patients with targeted, high risk and high-cost diagnoses.
• Independently perform difficult and complex assessment, review, coordination, planning, monitoring, evaluation, and analysis of cases.
• Screen potential case management clients, following identification for appropriateness/benefit of case management services. Interviews and provides individual counseling, as needed.
• Address services needed to optimize current health, psychosocial, spiritual status, and benefits of case management services.
• As required, enter approved metrics, patient data, and clinical progress notes into a prescribed database.
• Conduct a comprehensive assessment of patients, to establish in detail and specificity, the nature of their care needs, as well as causal and contributing conditions and circumstances.
• Conduct comprehensive clinical interviews with the patient and other family members, as warranted, and collect pertinent data from all involved healthcare agencies, medical providers, and resource programs.
• Participate in a multi-disciplinary team to develop a treatment plan to address all identified conditions and problems.
• Identify psychosocial aspects of anticipated care needs, to identify potential barriers to optimal health, resource utilization, and methods for minimizing such barriers.
• Assist the patient and the family in developing, documenting, and implementing appropriate care plans, and accessing agencies and care providers.
• Apply a holistic approach to address health care needs, in collaboration with all health team members, to include the patient and the patient's family, as warranted.
• Serve as an advocate for patients, and their families, in obtaining services and support.
• Serve as a senior nursing leader and advance the nursing profession in case management. Introduces innovative nursing techniques, practices, and approaches, in collaboration with health care providers, to identify, plan, assess, and coordinate care programs, designed to provide efficient, comprehensive, and cost-effective service for case-managed patients, throughout the continuum of care.
• Conduct training in nurse case management for professional and paraprofessional personnel, within the medical treatment facility (MTF).
• Provide education, counseling, and clinical assistance, in advanced techniques, to nursing personnel, medical students, interns/residents, staff physicians, and administrators.
• Provide formal and informal consultation, briefings, and educational offerings.
• Represent the case management service, on or before, a variety of committees, boards, agencies, and concerned groups, as directed.
• Coordinate with a patient-focused multidisciplinary team of clinicians to develop timeline protocols and high-quality, affordable health care for selected case-managed patients and beneficiaries, facilitating desirable patient outcomes.
• Identify strategies to improve patient access, reduce administrative burdens for DOD beneficiaries, and improve the cost-effectiveness of the civilian/military health care delivery system. Identify problems with healthcare access and utilization, in both the military and civilian sectors, and recommend alternatives to overcome difficulties. Interface with local, state, and federal agencies in obtaining regulations, policy manuals, and handouts, developing procedural guidelines to provide access to available programs. Ensure guidelines comply with case management standards of practice. Propose regulatory and administrative changes to resolve identified problems or concerns.
• Coordinate patient care through a continuum and facilitate the achievement of optimal outcomes in relation to care, quality, and cost-effectiveness.
• Maintain excellent patient assessment skills, use the nursing process as a basis for professional practice, and demonstrate proper preparation of patients for treatments and procedures, including surgical interventions.
• Prescribe and communicate treatment plans in accordance with established acceptable practices in established MTF policy and procedures and IAW JC guidelines. Telephone and in-person assessment/evaluation includes the determination of optimal time and location for patient management (ER, clinic, homecare) and follow-up care as required.
• Collect and assess significant patient history information and perform all necessary patient teaching.
• Demonstrate and adhere to peri-operative, infection control, and safety policies and procedures used in the MTF and IAW JC guidelines.
• Schedule referral appointments, arrange for procedures, and perform telephone follow-up, as appropriate.
• Ensure compliance with the standard of care and practice in accordance with all established policies, procedures, and guidelines used in the medical treatment MTF and IAW JC guidelines.
• Provide care within ethical and legal boundaries.
• Complete orientation and competency verification programs in accordance with unit guidelines.
• Serve and participate in committees, functions, and other meetings, when assigned.
• Provide relevant and timely information, and assist with decision-making and process improvement.
• Report to the Nurse Manager, and take direction from the charge nurse and house supervisor as required in maintaining a safe environment for staff and patient(s).
• Participate in the orientation, training, and evaluation of duty performance of newly assigned personnel, as appropriate, when required.
• Participate in customer service initiatives and medical readiness activities designed to enhance health services, as required.
• Document as directed, the disposition of referrals, MEPERS, and EOM reports, and actively participate in weekly/bi-weekly medical management conferences and report any updates to the staff on practice guidelines. Follow a systematic process to identify patients in need of referrals. Report high-risk, high-cost, and difficult patient situations, to the Department Head as indicated. Provide orientation for others new to the role and/or the facility. Maintain education specific to the department and certification requirements as necessary.
• Document as directed, the Case Management (CM) workload and patient care plans, MEPRS, EOM reports, and actively participate in weekly case management patient care conferences. Follow a systematic process to identify patients for referral to Case Management. Report high-risk, high-cost, and difficult situations, to the Department Head as indicated. Provide orientation for Case Managers new to the role and/or the facility. Maintain education specific to the department and certification requirements as necessary.
• Serves as advisor and consultant regarding the development, implementation, and management of the MTF healthcare UM/RM activities. Utilizes critical thinking skills to support, coordinate, and implement all aspects and stages of the UM/RM program, identifying patient care process improvements, through continual review of processes.
• Utilizes critical thinking skills to support, coordinate, and implement all aspects and stages of the UM/RM program, identifying patient care process improvements, through continual review of processes.
• Entails coordination of clinical care and services for active-duty service members, family members, and retirees covered by the Tricare Prime insurance benefit. Case Management recipients may have experienced a catastrophic injury or have been newly diagnosed with a chronic illness requiring the extensive use of resources and who need help navigating the system to facilitate appropriate delivery of care and services. Performance primarily in a cubicle in Building 17B, but the position will also require an office in Behavioral Health in Building 19.
• Responsible for tracking and monitoring active-duty cases admitted for behavioral health issues, alcohol and drug-related issues, as well as traumatic brain injuries.