Location: Keesler AFB, MS
Schedule:Duty schedule for personnel will be Compressed Work Schedule which will consist of 9 hour shifts Monday through Thursday between 0600 – 1800 and an 8 hour shift on one Friday between 0600 – 1800 with the alternate Friday off. Shifts will not exceed 9 hours Monday – Thursday and 8 hours on the working Friday and 80 hours in 2 weeks. All days will include an uncompensated 60 minute lunch break.
Benefits: PTO, sick leave, holiday leave, Life, Accidental Death and Dismemberment, Short Term Disability
Optional Benefits: Medical, Dental, Vision, 401(K) matching with employee participation in 401(K) plan
Responsibilities:-Provides comprehensive Disease Management (DM) services, applies and promotes DM,
health promotion, and wellness concepts and strategies to assigned patients and those
identified for DM.
-Assesses, plans, develops, coordinates, implements, and evaluates preventive and clinical
services for all assigned beneficiaries covering comprehensive primary, secondary, and
tertiary prevention/intervention across the population health continuum ranging from
normal to those having complex complications.
-Implements disease management services for populations with chronic conditions,
collaborates with patients in formulating patient-centered goals, and educates individuals
and groups based on clinical practice guidelines (CPGs) approved by the Executive
Committee of the Medical Staff.
-Proactively collaborates with the patient and healthcare teams, and utilizes evidencebased tools, such as predictive analytics, to identify patients who would benefit from
disease-specific education and patient-centered care. Conducts a thorough evaluation of
the patient’s current physical, psychosocial, and health status. Documents treatment plans
and matches the level of patient care to clinical risk, readiness to change, and health literacy. The goal is to promote self-management, prevent or delay the progression of
disease, improve clinical and financial outcomes, and advocate appropriate resource
utilization.
-Facilitates identification, adoption, implementation and utilization of standardized CPGs
and protocols for management of specific diseases and conditions. Educates/trains
teams/staff on policies and procedures for the utilization of guidelines, protocols, and
other disease management activities.
-Identifies, develops and executes appropriate multidisciplinary disease management
activities and interventions in collaboration with the Chief of Medical Staff, Chief Nurse,
Health Care Integrator, Medical Management Director, Behavioral Health Care
Facilitator, Case Manager, Utilization Manager, Discharge Planner, Group Practice
Manager, and primary/specialty care teams in support of population health and
population health management initiatives.
-Identifies, collects, interprets, and evaluates measurable outcomes of care within
established time frames (e.g., quality of services, cost and cost savings, disease
management, and continuous process 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/Medical
Management Director and Chief of Medical Staff. Reports disease management-related
data, process and outcome measures, identified opportunities for improvement, status of
process improvement programs and other requested information to MTF leadership
through committees, such as Population Health Working Group. Develops and evaluates
the annual disease management plan for inclusion in the population health plan in
collaboration with stakeholders.
-Provides a direct person-to-person summary (i.e., verbal communication providing
continuity of care and a seamless transfer of information) of patients transitioning to
other levels or places of care by providing pertinent information to the receiving
healthcare provider (e.g., patient self-management status at graduation from the disease
management program to primary care team, or transfer to case management for more
sensitive services); documents direct person-to-person summary in the electronic health
record.
-Documents disease management-related care provided using the ELAD Medical Expense
and Performance Reporting System (MEPRS) code for all face-to-face, telephonic, or
TRICARE Online Patient Portal Secure Messaging interactions. Coding will include
current International Classification of Diseases (ICD),Evaluation and Management
(E&M), and disease management-specific Healthcare Common Procedure Coding
System (HCPCS) codes, and the encounters must be completed and signed within three
business days.
-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 disease management.
Participates in the orientation, education, and training of other staff. Orients healthcare
teams to the purpose of DM activities, population health, clinical preventive services, and
medical management.
-May participate in committees, working groups, and task-forces at the MTF. Completes
all required training and competency verification programs in accordance with (IAW)
DHA, Air Force Medical Operations Agency, and MTF-level guidance. Participates in
continuing education programs to update and maintain skills and knowledge to meet
annual requirements.
-Conducts standardized peer review or gap analysis as directed by DHA/AF guidance,
under the Chief Nurse’s approval.
-Maintains a level of productivity and quality consistent with complexity of the
assignment; facility policies and guidelines; established principles, ethics, and standards
of practice of professional nursing; designated VA/DoD Clinical Practice Guidelines,
American Diabetes Association, and other evidence-based disease management
professional guidelines; Accreditation Association for Ambulatory Health Care
(AAAHC); Utilization Review Accreditation Commission (URAC); Health Services
Inspection (HSI); Joint Commission; and other applicable DoD/DHA/AF/MTF and
service-specific guidance and policies. Must comply with Equal Employment
Opportunity (EEO) Program, infection control and prevention, and patient safety policies
and procedures.
• Degree/Education: Registered Nurse – Disease Manager shall be a
graduate from an associate (ADN) or baccalaureate degree (BSN) program in
nursing accredited by a national nursing accrediting agency recognized by the
US Department of Education.
• Certifications in addition to Basic Life Support (5.2.3): Be eligible for any
national recognized disease or chronic care management certification.
• Experience: Minimum two years of recent full-time experience (within the last
four years) in management of patient populations with prevalent and chronic
diseases.
• Licensure/Registration: Current, full, active, and unrestricted license to practice as a Registered Nurse
as required in the TO.
AKAHI ASSOCIATES LLC
AKAHI Associates is a premier provider of healthcare workers to various military treatment facilities across the United States. With a corporate office in Honolulu, Hawaii and recruiting office in San Antonio, Texas we specialize in providing skilled, trained and highly successful healthcare workers, including RNs, CRNAs, Physicians, LPN/LVN, Licensed Social Workers, and many more.
We have a strong focus on providing our government customers with quality and superior service.
Akahi Associates is an equal opportunity employer and Minorities, Females, Veterans, and Disabled persons are encouraged to apply. For further information, please click the link below to view the EEO Is The Law poster.
Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.
Only qualified individuals who are being considered will be contacted for an interview.
Akahi Associates is an equal opportunity employer. For further information, please click the link to view the “Know Your Rights: Workplace Discrimination is Illegal” poster.
Know Your Rights: Workplace Discrimination is Illegal
Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability, protected veteran status, or other characteristics protected by law.
Only qualified individuals who are being considered will be contacted for an interview.