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RN - Registered Nurse Case Manager/Care Coordinator - Patient Aligned Care Team
2 months ago
VA offers a comprehensive total rewards package: VA Nurse Total Rewards
This position is eligible for the Education Debt Reduction Program (EDRP), a student loan payment reimbursement program. You must meet specific individual eligibility requirements in accordance with VHA policy and submit your EDRP application within four months of appointment. Program Approval, award amount (up to $200,000) and eligibility period (one to five years) are determined by the VHA Education Loan Repayment Services program office after complete review of the EDRP application.
Duties and responsibilities included but not limited to:
Exhibits leadership in promoting proactive and evidence-based care by bringing up to date research and data to the team and leading process improvements to keep team practices current and safe based on High Reliability Organization (HRO) principles.
Participates in chronic disease management for panel in collaboration with provider. Engages in Shared Medical Appointments (SMA), Group visits, Team visits and/or RNCM visits.
Utilizes the Primary Care Almanac and PACT Metrics to address population health management issues and improve Team processes.
Triages and applies a collaborative team approach in identifying, analyzing, and resolving patient care problems.
Assists in determining appropriate scheduling based on patient's clinical needs. Right person, right place, right time.
Collaborates with ancillary team members and resources within the clinic to manage clinic access issues. This may include assisting other nursing staff with maintaining clinic flow.
Serves in a role to support Telehealth and VA Video Connect programs across the system.
Exhibits leadership in promoting proactive and evidence-based care by bringing research and data to the team and leading process improvements to keep team practices current.
Promotes patient, family and team interactions, and problem solving by actively participating in interdisciplinary meetings to facilitate coordination and the achievement of identified goals.
Retains current knowledge of multidisciplinary resources, programs, and services, referring patients to community resources as appropriate. Demonstrates ability to collaborate and coordinate with all levels of services and disciplines.
Collaborate with patients to assess and identify needs, issues, care goals, and resources for achieving desired outcomes post hospital recovery and health maintenance/wellness by effectively using Motivational Interviewing and TEACH techniques.
Supports patient self-management by providing an ongoing relationship with the PACT with current information regarding all options, choices, and resources. Provides patient centered care while respecting patient's personal values, cultural, and belief system.
Utilizes approved Protocols and Guidelines to facilitate autonomy in providing care. Works at the top of scope of practice.
Accurately documents coordination and care provided in CPRS.
Manages patient care alerts in CPRS and secure messages in a timely, safe, and effective manner.
Serves as a resource for patient and family rights, responsibilities, and decision-making information and processes.
Actively participates in reviewing and updating policies, procedures, and standards to promote evidence-based, patient-driven care.
Maintains expertise in chronic care/disease management and Health Promotion/Disease Prevention.
Pay:
Competitive salary, regular salary increases, potential for performance awards
Paid Time Off:
50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year)
Retirement:
Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA
Insurance:
Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)
Licensure:
1 full and unrestricted license from any US State or territory
Work Schedule:
7:30 am - 4:00 pm, Supervisory Discretion
Telework:
Not Available
Virtual:
This is not a virtual position.
Relocation/Recruitment Incentives:
Not Authorized
EDRP:
Authorized
.
Former EDRP participants ineligible to apply for incentive. Contact v21ccoeedrp@va.gov, the EDRP Coordinator for questions/assistance.
Learn more
Permanent Change of Station (PCS)
: Not Authorized
Financial Disclosure Report:
Not required
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