RN Discharge Planner

Location: Keesler AFB, MS

Pay - $35/hr base and $4.93/hr for H&W

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

Develops and executes discharge planning activities for the MTF. Follows all approved
discharge planning Clinical Decision Support Tool (CDST) criteria.
Ensures collaborative communication processes exist between the primary care and
medical management teams. Collaborates with the Health Care Integrator, other medical
management staff, and primary/specialty care teams to plan and implement population
health strategies.
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 nursing, discharge planning,
and case management.
Attends and participates in meetings during regular duty hours, professional staffing
services, and other appropriate professional activities such as, but not limited to the
following: Population Health Function (PHF) meeting, Medical Management (MM) staff
meetings, and others required by applicable regulations, DHA/DoD/AF/MTF guidance,
or as directed by the Director of Medical Management or his/her designated
representative.
Participates in the orientation and training of other staff. May serve on committees,
workgroups, and task-forces at the facility. Completes all required training and
competency verification programs in accordance with (IAW) DHA, Air Force Medical
Operations Agency, and MTF-level guidance. Follows applicable DoD/DHA/AF/MTF
instructions, policies, and guidelines.
Maintains a level of productivity and quality, with minimal supervisory direction,
consistent with complexity of the assignment; facility policies and guidelines; established
principles, ethics and standards of practice of professional nursing; the Case Management
Society of America (CMSA); Accreditation Association for Ambulatory Health Care
(AAAHC); Utilization Review Accreditation Commission (URAC); Joint Commission
(JC); and other applicable DoD/DHA/AF/MTF and service-specific guidance and
policies. Must also comply with Equal Employment Opportunity (EEO) Program,
infection control and prevention, and patient safety policies and procedures.
Completes medical record documentation, coding, and designated tracking logs and data
reporting as required by local MTF/DoD/DHA/AF instructions, policies, and guidance.
Documents a comprehensive discharge plan in the electronic health record. At a
minimum, the documented plan of care focuses on achieving a safe/timely discharge,
addresses community resources and durable medical equipment (DME) needs,
interventions, and expected goals/outcomes to be achieved and actions designed to meet
the assessed needs for healthcare, safety, and attainment of patient’s health goals as
agreed to by the discharge planner, the patient/family/caregiver, provider, and other
members of the interdisciplinary team. Documentation must be completed within the duty
day. Conducts standardized peer review or gap analysis as directed by DHA/AF
guidance, under the Chief Nurse’s approval.

Assessment: Proactively identifies and evaluates patients and families for discharge
planning activities from a variety of sources such as discharge/disposition planning,
referrals, the Medical Evaluation Board (MEB) process, the healthcare system,
employers, and facility staff. Conducts systematic, on-going, thorough collection of
patient’s physical, emotional, psychological, social, and medical status and information
via direct patient communication and other relevant sources such as professional and nonprofessional caregivers, medical records, and family/caregiver interviews.
Planning: Develops an appropriate patient-specific plan of care to include short and
long term goals, objectives, and actions. Coordinates, collaborates, and obtains approval
of the discharge plan among the patient, family/caregiver, primary provider, and other
members of the healthcare team.
Referral: Considers all needs for referrals to include TRICARE authorizations, DME,
special needs equipment/services, ongoing specialty medical care, case management, and
institutional referrals such as transfers for rehabilitative or nursing home care.
Implementation: Guides the patient and family/caregiver through the healthcare system,
maximizing the use of resources. Coordinates and executes the plan of care, optimizing
access to appropriate services. Ensures necessary referrals are ordered by the appropriate
discipline and coordinated. Serves as an advocate for and ensures education is provided
to the patient and family/caregiver as required. Promotes adherence to treatment plans for
improved healthcare outcomes. Reviews the discharge plan with the patient and the
patient’s family/caregiver prior to discharge and documents the review in the patient’s
medical record.
Coordination: Ensures coordination of care delivery processes, to include alternate
healthcare settings and the home environment, to enhance the patient's health and
wellness, safety, productivity, and quality of life, and for providing the most beneficial,
cost-effective healthcare. Develops, utilizes, and maintains a variety of military and
community resources to optimize access to services and medical care. Ensures timely and
appropriate provision of services.
Monitoring: Documents and updates the discharge plan as needed IAW existing DoD,
DHA, AF, local facility, and other agency guidelines. Maintains documentation and data
collection in accordance with DoD, AF, local facility, and other specified agency
guidelines. Has working knowledge of DRGs, ICD-10, CPT-4, HCPCS coding, and
Length of Stay (LOS), Avoidable Bed Days, and reducing readmissions.
Evaluation: Monitoring and evaluation may include, but is not limited to patient’s
adherence and response to the treatment plan; timeliness of patient and family/caregiver
contact and follow-up; identification of variances, patterns or trends from established
practice guidelines and/or standards; established outcome measurements; results of
interventions, treatment delivery and timeliness of care; and utilization of resources.

Conducts periodic evaluations of the quality and effectiveness of the discharge planning
process per DoD/DHA/AF/MTF policies and guidelines.

Degree/Education: Registered Nurse – Discharge Planner 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: None
• Experience: Minimum two years of recent full-time experience (within the last
four years) as a case manager or discharge planner, in an inpatient setting
providing care for adults, children, families, seniors, or groups, or minimum
four years of recent full-time experience (within the last six years) in an
outpatient clinic setting providing case management for adults, children,
families, seniors, or groups.
• 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.