Registered Nurse, Special Needs Coordinator Position Description
QUALIFICATIONS:
* Education: Degree: Associates Degree of Nursing. Graduate from a college or university accredited by National League for Nursing Accrediting Commission (NLNAC), or The Commission on Collegiate Nursing Education (CCNE).
* Experience: Minimum three years of experience (ADN) full-time experience in
nursing and care coordination OR
Minimum two years of experience (BSN) full-time experience in nursing and care
coordination.
* Licensure: Current, full, active, and unrestricted license to practice as a Registered Nurse as required in the TO.
* Certification: Possess and maintain a current American Heart Association BLS Healthcare Provider certification.
* Must be a U.S citizen and have the ability to pass a background check/security clearance. CORE RN
DUTIES: The duties include but are not limited to the following:
• Coordinate patient care in collaboration with a wide array of healthcare
professionals. Facilitate the achievement of optimal outcomes in relation to clinical
care, quality and cost effectiveness.
• Ensure compliance with standards of care and practice in accordance with all
established policies, procedures, and guidelines used in the MTF.
• Perform physical exam and health histories.
• Provide health promotions, counseling, and education.
• Administer medications, wound care, and numerous other personalized interventions.
• Direct and supervise care provide by other healthcare professionals.
• Accountable for making patient care assignments based on the scope of practice and
skill level of assigned personnel.
• Recognize adverse signs and symptoms and quickly react in emergency situations.
• Communicate and collaborate with a diverse group of people for the purpose of
informing the healthcare team of plans/actions, for teaching/education to benefit the
patient/family and organization.
• Make referral appointments and arrange specialty care as appropriate.
• Perform nursing services identified in the TO.
• Conduct research in support of improved practice and patient outcomes.
Duties specific to position, but not limited to:
• Identification of patients that need special medical and education needs/management;
comprehensive collection of patient information and medical status; and continued
evaluation of an established plan of care.
• Collaboration with the patient, family/caregiver, primary provider and other members of
the health care team for developing an effective plan of care.
• Care coordination and communication among all involved parties.
• Support for the patient and family/caregivers to ensure identified education and
appropriate, timely care coordination is received.
• Ensures all active duty sponsors known to the AFPC, and local MPS and/or CSS where
applicable, as having family members with special needs are identified in AF medical special needs data management systems. Provides oversight for base-level data entry in AF-provided data management systems used in the management of EFMP-M.
• Integrally involved in the FMRC process. Ensures all FMRC requirements are implemented by all EFMP-M staff. Coordinates the enrollment process and travel
screening for all active duty family members’ and travel screening upon request to the families of DoD sponsored assignments going to an overseas base.
• Provides clinical oversight to ensure every AF sponsor with one or more family members
with special needs assigned to the installation has a SN file maintained at the MTF. Ensures Q-coded sponsors assigned to the installation are contacted annually to determine if there are unmet needs and to request updates of information as needed.
• Collaborates with the IDS and other interagency forums that provide family medical information and referrals to base and civilian agencies. Ensures EFMP families are referred to the AFRC for additional community assistance as needed. Maintains a
cooperative working relationship with the base MPS, CSS, and AFPC. Actively supports the integration of EFMP- M, EFMP-FS and EFMP-A services at the installation. Provides information, appropriate contact information, and coordinates referrals as appropriate.
• Participates in EFMP quarterly case reviews to discuss assess newly identified families’, complex, or unmet clinical needs. Determine the appropriate resources necessary for the families.
• Patient specific assessments and clinical plans of action will be located in AHLTA and
the Special Needs record. Meeting minutes will not contain patient identifying
information.
• Coordinates and participates in designated facility meetings.
• Participates in the clinic orientation and training of other staff of the Special Needs
Program. May serve on committees, work groups, and task forces at the facility.
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