RN Disease Manager

Profile: We offer remote work opportunities (AZ, CA, *CO, IA, ID, MN, MO, MT, NV, NM, OR, SD, TX, UT, *WA, WI & WY only) Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position. Veterans, Reservists, Guardsmen and military family members are encouraged to apply! Job Summary: Provides Disease Management (DM) services to TRICARE beneficiaries. The DM nurse will collaboratively assess, plan, implement, coordinate, monitor and evaluate the beneficiary’s health and psychosocial needs with a focus on empowering the beneficiary to successfully manage their chronic condition. The DM nurse will partner with the interdisciplinary care team to identify appropriate care to prevent complications related to chronic conditions and minimize the risk of potential exacerbation through the use of evidence-based condition-specific education and coaching. This role requires the individual to develop care plans in collaboration with providers, patients, families as appropriate and assesses the effectiveness and outcomes to improve individual health status.

Assess beneficiaries to identify medical, physical, and psychosocial needs to support the beneficiaries overall goals of care. Ensure and evaluate clinical appropriateness of care plan by incorporating assessment findings against evidence-based guidelines, clinical reasoning and clinical practice guidelines. Provide education and coaching specific to the beneficiary needs to prevent to prevent exacerbations or worsening chronic conditions. Manage activities necessary to ensure appropriate utilization and access to resources while maintaining optimal standards of care. Review, identify and assist with identification and facilitation of resources related to health disparities identified through SDOH assessment. Participates in the development of measurable outcomes, ensures measure are in place to monitor the impact of programs and services on the health status of beneficiaries being managed. Facilitate transfer of beneficiary between the different regions and within the regions by collaborating with the military liaison to support the transition with minimal disruption. Adhere to URAC standards, TRICARE policy, contractual requirements, and nationally recognized practice standards. Regular and reliable attendance.