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Registered Nurse-Ambulatory Care Service Patient Aligned Care Team

2 months ago

North Conway, United States Veterans Health Administration Full time

Included but are not limited to:
Plays an integral role in the Patient Aligned Care Team (PACT) providing initial and ongoing assessment of patients and functioning as a systems coordinator for the plan of care.
Initiates PACT preplanning for scheduled clinic visits, participates in daily huddle and team meetings to collaborate how best to meet the patients' needs.
Conducts follow up calls to hospitalizations and Emergency Department visits, reviews records, and coordinates follow-up care.
Participates in direct patient care surrounding scheduled and unscheduled visits.
Manages a designated panel of patients and utilizes VA developed protocols to enhance preventions as well as manage chronic diseases including HTN, DM, COPD, CHF.
Identifies and care manages high risk patients via face-to-face visits, virtual video connect, secure messaging, and telephone calls.
Coordinates transitions for patient care with specialists and consultants.
Conducts comprehensive assessment of patients' needs and ensures patients are linked with all appropriate services, resources and opportunities based on his or her needs.
Partners with Veteran to support self-management, prevention, and wellness, utilizing Health Coaching and Motivational Interviewing to assist with behavior change and guidance towards his or her goals.
Provides patient-centered, evidence-based, patient driven care in all patient interactions across the care continuum.
Lab phlebotomy, point-of-care testing, and specimen labeling.
Occasional travel may be required for education, organizational needs, or to provide nursing support at the other CBOC locations (Portsmouth, Tilton, Conway), or at the Manchester VA Medical Center.



Work Schedule:
Full Time, Monday-Friday 7:30am-4:00pm; 8:00am-4:30pm


Compressed/Flexible:
Not Authorized


Telework:
Not Available


Virtual:
This is not a virtual position.


Permanent Change of Station (PCS)
:Not Authorized


Financial Disclosure Report:
Not required




Notifications:

This is a Bargaining Unit Position
This position is in the Excepted Service
This position is covered by a special rate.
Current and former Federal employees must submit copies of their most recent SF-50, (Notice of Personnel Action). The SF-50 must identify the position title, series, grade, step, tenure and type of service (Competitive or Excepted). In some cases, more than one SF-50 may be required to show a higher grade previously held



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



VA offers a comprehensive total rewards package:
VA Nurse Total Rewards