Dayton, OH
30+ days ago


This is a position listing for a Registered Nurse (RN) - Discharge Planning position at the Wright-Patterson AFB, Dayton, OH. 

All Luke & Associates positions have the sole purpose of providing quality medical attention to veterans, the military, and their families. Our commitment is to our employees, our clients and of course the patients and their safety.



  • Wright Patterson Medical Center, 4881 Sugar Maple Dr, WPAFB, OH.  
  • HCWs shall receive notification two weeks prior to the reassignment to another location with a 40-mile commuting radius of their assigned MTF. 
  • Due to the relative unpredictability of the military mission, the occasion of deployed or otherwise occupied service members can disrupt the provision of health care in specialized medical product lines, especially those of one deep skill sets. 
  • When a key staff member is deployed or otherwise occupied for extended periods, the remaining product line FTEs may be left struggling to be gainfully employed. 
  • Flexibility is required to temporarily move contracted staff within the Squadron to similar duty responsibilities/locations


  • Degree/Education: HCW must be a graduate from a baccalaureate degree program in nursing accredited by a national nursing agency that is recognized by the National League for Nursing Accrediting Commission (NLNAC), or The Commission on Collegiate Nursing Education (CCNE).  May consider a graduate from an associate degree program with 5 years full-time specific discharge planning or case management experience until 1 June 2019.  HCWs are required to maintain Continuing Education as required by their State Board of Nursing. Periodic Continuing Nursing Education may be available at the MTF, at no cost to the contractor, for HCWs desiring to attend on a space available basis.
  • Certifications in addition to Basic Life Support: Certification is not available at the MTF’s Education and Training department. The Contractor shall not bill, and the Government shall not pay for any time HCWs spend on certification training. Failure of the HCW to obtain training does not release the Contractor from the contract requirement.  HCW must possess one of the following certifications:
  • Commission for Case Manager Certification Certified Case Manager (CCM)
  • Certification of Disability Management Specialists Commission: Certified Disability Management Specialist (CDMS)
  • Association of Rehabilitation Nurses: Certified Rehabilitation Registered Nurse (CRRN)
  • American Board for Occupational Health Nurses Certified Occupational Health Nurse (COHN) or Certified Occupational Health Nurse-Specialist (COHN-S).
  • National Board for Certification in Continuity of Care: Advanced Certification in Continuity of Care (ACCC)
  • Commission on Rehabilitation Counselor Certification: Certified Rehabilitation Counselor (CRC)
  • American Nurses Credentialing Center Nurse Case Manager (RN-NCM)
  • National Academy of Certified Care Managers: Care Manager Certified (CMC)
  • Experience:  Two years full-time experience in discharge planning or case management is required for graduates with a Bachelor of Science in Nursing.  A minimum of 5 years’ experience in discharge planning or case management is required for consideration of a candidate with an Associate Degree in Nursing. 
  • Licensure/Registration:  Registered Nurse; Current, full, active, and unrestricted license to practice as a Registered Nurse in any US jurisdiction.  Licensed in good standing and cannot be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/certification agency. Licensing status must be unrestricted.
  • U.S. Citizenship: HCWs performing under this contract shall be U.S. citizens.
  • Able to read, write, and speak English well enough to effectively communicate.
  • Shall be physically capable of standing and/or sitting for extended periods of time and physically capable of performing all services required under the contract and TO.

DUTIES: The duties for the HCW are as follows:

  • Assessment.  Proactively identifies and evaluates patients for discharge planning/case management within 24 hours of identification or notification, or by close of the first business day after a weekend or holiday. Conducts systematic, on-going, thorough collection of patient’s physical, emotional, psychological, social and medical status and information via direct patient contact, family/caregiver, and other relevant sources such as professional and non-professional caregivers.  Reviews the patient’s medical record against clinical decision support tool for discharge planning criteria to determine readiness for discharge.
  • Planning. Develops an appropriate patient-specific discharge plan of care within 3 working days.  Coordinates, collaborates, and obtains approval of the plan among the patient, family/caregiver, primary provider and other members of the healthcare team.  Documents review of the plan in the patient’s medical record.
  • Implementation. Coordinates and executes the discharge plan with the patient and family/caregiver, 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 the discharge plan for improved healthcare outcomes.
  • Coordination. Ensures coordination of care delivery processes, to include alternate healthcare settings and the home environment, for the purposes of enhancing the patient's health and wellness, safety, productivity, and quality of life, and for providing the most beneficial, cost-effective health care.  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. Ensures patient has follow-up appointment with appropriate provider/s prior to discharge.
  • Monitoring. Re-evaluates the patient and the plan every 72 hours until discharged per clinical decision support tool, aligning the plan with health insurance and/or TRICARE benefits and policies. Documents in accordance with existing local facility/AF/DHA and other agency guidelines.   Maintains data collection in accordance with local facility/AF/DHA and other specified agency guidelines. Such data includes but is not limited to resource utilization and patient outcomes, and Length of Stay (LOS) and Avoidable Bed Days, analyzing for variance, appropriate interventions and cost containment.
  • Evaluation.  Actions may include timeliness of completion of the discharge plan, patient’s adherence and response to the plan, 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.  Monitors and evaluates the facility’s discharge planning program per local facility/AF/DHA policies and guidelines.
  • Coordinates and participates in interdisciplinary team meetings, designated facility meetings, and Discharge Planning meetings.  Shares knowledge and experiences gained from own clinical nursing practice and education relevant to nursing, discharge planning and case management, and utilization management.
  • Participates in the orientation and training of other staff.   May serve on committees, work groups, and task forces at the facility.
  • Must maintain 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; the Case Management Society of America (CMSA); American Accreditation Healthcare Commission/Utilization Review Accreditation Commission (URAC); CAMH; (AAAHC); Health Services Inspection (HSI); and other applicable DHA and Service specific guidance and policies. Must also comply with the Equal Employment Opportunity (EEO) Program, infection control and safety policies and procedures. 
  • Completes medical record documentation and coding, and designated tracking logs and data reporting as required by local facility/AF/DHA instructions, policies and guidance. 
  • Completes all required electronic medical record training, facility-specific orientation and training programs, and any AF/DHA mandated training.
  • Conducts nursing peer reviews no less than quarterly as assigned.
  • Follows applicable local facility/AF/DHA instructions, policies and guidelines.


  • 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.
  • Conduct research in support of improved practice and patient outcomes.
  • Participate in all phases of the Case Management Program (CMP) and ensure that the CMP meets established case management (CM) standards of care.
  • Provide nursing expertise about the CM process, including assessment, planning, implementation, coordination, and monitoring. Identify opportunities for CM and identify and integrate local CM processes.
  • Develop and implement local strategies using inpatient, outpatient, onsite and telephonic CM
  • Develop and implement tools to support case management, such as those used for patient identification and patient assessment, clinical practice guidelines, algorithms, CM software, and databases for community resources.
  • Integrate CM and utilization management (UM) and integrating nursing case management with social work case management.
  • Maintain liaison with appropriate community agencies and organizations.
  • Accurately collect and document patient care data.
  • Develop treatment plans including preventive, therapeutic, rehabilitative, psychosocial, and clinical interventions to ensure continuity of care toward the goal of optimal wellness.
  • Establish mechanisms to ensure proper implementation of patient treatment plan and follow-up post discharge in ambulatory and community health care settings.
  • Provide appropriate health care instruction to patient and/or caregivers based on identified learning needs.


  • Contract HCWs will submit routine schedule change requests with at least 2 week notice. 
  • Schedules may vary depending on mission needs; such as; required training outside core duty hours 0730-1630. 
  • Discharge planners may have altered duty scheduled between the hours of 0600-1800 due to inpatient schedules, such as provider rounds, advance notice will be given to HCWs.
  • All HCWs will submit planned vacation time for the year prior to 28 February of each year, to allow for coverage planning.  HCWs will verify needed time off prior to 31 August of each year to prevent unplanned use-or-lose leave requests, and to allow government time to plan for department coverage during the holidays.
  • HCWs will provide contact information for department recall roster.  Information is used only for official business; i.e. mandatory recall to relay mission essential information and duty reporting instructions.
  • Contractor will be required to attend periodic progress meetings at no additional cost to the Government. The terms at which the periodic meeting will be conducted include: Semi-annually and as requested for unresolved performance concerns. Telephone conferences are acceptable.
  • Overage Hours:  Overage hours are times the HCW must remain at the facility for continuity of care reasons.  The Government identifies overage hours as hours beyond the duty hours on the work schedule. Registered Nurse- Discharge Planner: 50 hrs per contract year spread as needed between 2 FTEs, to be approved by government supervisor in advance of performing overtime.


Must be comfortable in a fast-paced, dynamic environment.  Must be able and willing to reprioritize on short notice and work on multiple simultaneous projects.  Flexible and able to work with various personalities.  Team work skills required. Time management skills required. The ability to meet deadlines in a deadline intensive environment is essential. High level of adaptability and willingness to embrace change in a fast-paced, demanding environment.

Luke & Associates does not discriminate on the basis of race, sex, color, religion, national origin, age, disability or veteran status in provision of services or employment opportunities and benefits. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, or national origin. 



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