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Clinical Nurse-Disease Manager

Nursing | San Antonio, TX | Full Time

Job Description


San Antonio TX

An established and successful Texas-based Workforce Solutions Company is currently looking for a full-time Clinical Nurse-Disease Manager to provide services located at a Joint Base in San Antonio.  The position offers a structured M-F 8-hour work day which makes for a great work/life balance.  It also allows health care workers to service our military and their families to make a difference in their quality of life.  Come make a difference servicing our military and their families!


Utilizing major components of population health and disease management, ensures health care interventions for individuals and populations of patients with prevalent and/or chronic diseases in order to achieve disease management compliance, improved overall quality of life, and reduced healthcare costs. Also performs clinical nursing care in the execution of disease management services. 


  • Graduate of an accredited nursing program BSN or ADN
  • Maintain an active, valid, current, and unrestricted license (with no limitations, stipulations or pending adverse actions) to practice nursing as a registered nurse in any US state/jurisdiction. 
  • Possess a minimum of 3 years for ADN or 2 years for BSN full-time experience in management of patient populations with prevalent and chronic diseases. 
  • Minimum 3 years clinical experience in acute care setting. Candidates must be specialty certification eligible, from any of the certifications listed below. 
  • Acceptable certifications include CCP (Chronic Care Professional), Certified Diabetic Educator, Board certified Advanced Diabetes Management certification (BC-ADM)
  • Certification in disease-management related area such as: Chronic Care Professional (CCP) by Health Sciences Institute or Certified Health Coach (CHC) by National Society of Health Coaches; or a patient education body such as: Certified Diabetes Educator (CDE) by National Certification Board for Diabetes Educators or Certified Asthma Educator (AE-C) by National Asthma Educator Certification Board; -OR- can be certification eligible with 3 years for ADN or 2 years for BSN of full-time disease management experience.
  • Knowledgeable of clinical and administrative theories, principles, practices, and procedures underlying nursing practices
  • Skilled in analyzing and defining healthcare needs of a defined population using standardized assessment tools; administrative requirements for proper documentation of patient’s condition(s)


  • Coordinates patient care through a continuum and facilitates the achievement of optimal outcomes in relation to clinical care, quality and cost effectiveness. 
  • Identifies and stratifies individual patients and populations of patients across the spectrum of care at risk for chronic diseases and co-morbid conditions and evaluates the incidence of such conditions from a variety of established data bases and facility treatment team referrals. 
  • Facilitates identification, adoption, implementation and utilization of standardized clinical practice guidelines and protocols for management of specific diseases/ conditions. 
  • Identifies, develops and executes appropriate disease management activities and interventions such as, but not limited to, individual and/or group patient contacts and training classes. 
  • Conducts a thorough evaluation of the patient’s current physical, psychosocial and health status. Documents treatment plans and the matches level of patient’s care to clinical risk, readiness to change and health literacy. 
  • Educates/trains team/facility staff on policies and procedures for utilization of guidelines, protocols and other disease management activities. Fosters collaboration and facilitates disease management  
  • activities with the patient care team. 
  • Identifies, collects, interprets and evaluates measurable outcomes of care within established time frames (i.e., quality of services, cost and cost savings, disease management and improvement). Conducts special studies as indicated based on outcomes and other Quality Management/Risk Management and Population Health programs and indicators. 
  • Reports data as required in coordination with the Health Care Integrator and Chief of Medical Staff. Reports disease management efforts to MTF leadership through committees such as Population Health Working Group. 
  • Proactively coordinates with the Case Manager and Utilization Manager as needed. 
  • Assists in development of facility’s Medical Management/Population Health plan in support of the annual Business Plan, ensuring a process for collecting disease management data, monitoring  
  • performance, and identifying improvement opportunities. 
  • Recognizes adverse signs and symptoms and quickly reacts in emergency situations. 
  • Completes in-person and telephonic evaluations that include determination of optimal time and location for patient management (i.e., ER, clinic, homecare) and follow-up care as required. Prescribes and communicates treatment plan and patient teaching in accordance with established protocols.  
  • Collects and assesses significant patient history information and performs all necessary patient teaching. 
  • Demonstrates skill in setting up, operating and monitoring specialized medical equipment such as cardiac monitoring devices, EKG units, oxygen analyzers, nebulizers, and other clinic specific equipment.
  • Performs/assists with procedures such as medication administration, oxygen administration, bladder catheterizations, visual acuity tests, EKGs, irrigation of eyes and ears, tympanograms, splinting, phlebotomy and other clinic specific procedures, in accordance with established protocols. 
  • May be required to work an adjusted schedule or augment clinical nursing support during the absence of other team nurses due to illness, leave or deployment. 
  • Performs assigned duties and tasks in the execution of services to include, but is not limited to: nursing assessment, planning, implementation and evaluation of care; tele-health; medication administration; clinical nursing procedures and patient education. 
  • 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 and disease management. 
  • Participates in the orientation, education and training of other staff. May participate in committees, work groups, and task forces at the facility. 
  • Other duties as assigned


  • Competitive Pay
  • Health Benefits
  • 10 Paid Federal Holidays
  • 2 Weeks of PTO
  • Government Security Clearance

We support a diverse workforce and is an Equal Opportunity Employer who does not discriminate against employees and applicants for employment on the basis of race, gender, color, religion, national origin, age, sexual orientation, gender identity, genetic information, disability, veteran status or other classification protected by law.