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Brindar instrucción adecuada sobre atención médica al paciente y/o cuidadores según las necesidades de aprendizaje identificadas.\n\nFunciones adicionales:\n• Utilizar programas automatizados disponibles y herramientas de tecnología de la información, comunicación y gestión para una gestión proactiva del paciente, facilitar la participación del paciente y mejorar su experiencia (por ejemplo, MHS Genesis, TSWF, CarePoint y mensajería segura del portal del paciente).\n• Comunicarse con los pacientes utilizando mensajería segura asincrónica (por ejemplo, el portal del paciente de MHS Genesis) para mejorar la comunicación y facilitar la atención mediante medios no tradicionales.\n• Participar en todas las fases del Programa de Gestión de Casos (CMP) y asegurar que el CMP cumpla con los estándares establecidos de atención en gestión de casos (CM). Colaborar en la coordinación de un equipo multidisciplinario para satisfacer las necesidades de atención médica, incluyendo el manejo médico y/o psicosocial, de pacientes específicos.\n• Actuar como consultor para todas las disciplinas respecto a temas de gestión de casos. Brindar experiencia de enfermería sobre el proceso de gestión de casos, incluyendo evaluación, planificación, implementación, coordinación y seguimiento. Identificar oportunidades para la gestión de casos e identificar e integrar procesos locales de gestión de casos.\n• Desarrollar e implementar estrategias locales utilizando gestión de casos en pacientes hospitalizados, ambulatorios, presenciales y telefónicos; desarrollar e implementar políticas y protocolos para evaluaciones de salud domiciliaria y medidas de resultados.\n• Desarrollar e implementar herramientas para apoyar la gestión de casos, como las utilizadas para la identificación y evaluación de pacientes, guías clínicas, algoritmos, software de gestión de casos, bases de datos de recursos comunitarios, etc.\n• Integrar la gestión de casos y la gestión de utilización (UM) e integrar la gestión de casos de enfermería con la gestión de casos del trabajo social. Preparar informes rutinarios y realizar análisis.\n• Colaborar en el establecimiento y mantenimiento de contacto con las agencias y organizaciones comunitarias pertinentes, la oficina del Agente Principal de TRICARE y el Contratista de Apoyo de Atención Médica Administrada.\n• Mantener el cumplimiento de los requisitos regulatorios de JCAHO, URAC, CMSA y otros. Aplicar criterios de atención médica (por ejemplo, InterQual).\n• Asegurar la recopilación precisa y la entrada de datos del cuidado del paciente y garantizar una gestión básica del presupuesto de gestión de casos.\n• Proporcionar aportes sobre los recursos de gestión de casos del MTF y hacer recomendaciones al Mando sobre cómo pueden utilizarse mejor esos recursos.\n• Colaborar con los miembros del equipo multidisciplinario para establecer metas específicas para cada paciente. Desarrollar planes de tratamiento que incluyan intervenciones preventivas, terapéuticas, rehabilitadoras, psicosociales y clínicas para garantizar la continuidad de la atención con el objetivo de lograr el bienestar óptimo.\n• Establecer e implementar mecanismos para garantizar la correcta implementación del plan de tratamiento del paciente y el seguimiento posterior al alta en entornos de atención ambulatoria y comunitaria.\n• Brindar asesoramiento y consultoría de enfermería en persona y por teléfono.\n• Asegurar la instrucción adecuada sobre atención médica al paciente y/o cuidadores según las necesidades de aprendizaje identificadas.\n• Alertar a los médicos sobre cambios significativos o anomalías en los pacientes y proporcionar información sobre su condición relevante, historial médico y plan o protocolo de tratamiento especializado.\n• Facilitar la planificación multidisciplinaria del alta y otras reuniones del personal profesional según sea necesario para casos complejos de pacientes, y desarrollar una base de datos y conocimiento de los recursos comunitarios locales.\n• Desarrollar e implementar mecanismos para evaluar la satisfacción del paciente, la familia y los proveedores, así como el uso de recursos y servicios de manera consciente de la calidad y rentable.\n• Implementar estrategias para garantizar una transición fluida y un tratamiento continuo de atención médica para los pacientes cuando el miembro militar se transfiera fuera del área. Desarrollar una política para las transferencias de región a región y colaborar en su ejecución.\n• Facilitar la evaluación y colaborar en las transferencias de familias del Programa de Miembros Excepcionales de la Familia (EFMP).\n• Planificar el crecimiento y desarrollo profesional relacionado con el puesto de gestor de casos y el mantenimiento de la certificación en gestión de casos.\n• Establecer estrategias de contención de costos y reducción de gastos para la gestión de casos y desarrollar mecanismos para medir su eficacia económica.\n• Colaborar en la interfaz de gestión de casos u otras bases de datos diseñadas para apoyar la gestión de casos.\n• Participar en videoconferencias (VTC) y otras reuniones según sea necesario.\n\nHorario:\nLunes a viernes, turno de 8 horas entre las 6:00 a.m. y las 6:00 p.m.\n¡Sin fines de semana!\n¡Sin días festivos!\n\nRequisitos\n\nCalificaciones mínimas:\nTítulo: Poseer una licenciatura en enfermería de una universidad acreditada. 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