Nurse- Primary Care Health Program and Disease Prevention Program Manager

4 weeks ago

Detroit, Michigan, United States Veterans Health Administration Full time
Demonstrates advanced clinical knowledge in assessing, planning, implementing, documenting, and evaluating care for a designated group of patients across the continuum of care:
Recognizing the age-related cognitive, physical, emotional, and chronological maturation needs of the adult and geriatric patient.
Triages and applies a collaborative team approach in identifying, analyzing, and resolving patient care problems.

Collaborates with patients to assess and identify needs, issues, care goals, and resources in critical factors for achieving desired outcomes for discharge, post-hospital recovery, and health maintenance/wellness.

Maintains current knowledge of multidisciplinary resources, programs, and services, referring patients to community resources as appropriate.
Demonstrates ability to collaborate with all levels of services and disciplines.

Collaborates with the patient, family, and care providers in any and all settings where care is being provided to evaluate and update changes in the patient-driven life plan and patient management.

Reviews options with patients and families, including costs, alternatives, risks/benefits, and services. Advocates fiscal responsibility through monitoring the utilization of resources.

Identifies high-risk populations/chronic disease tracking and patients that could benefit from CCHT, HBPC, Clinical Pharmacy, and extended team members.

RN Care Managers have obtained access to databases:

VSSC and Vision 11 database allowing them to identify high-risk patients thru the almanac, compass, and CAN risk scores and will utilize nurse face-to-face clinics and non-face to-face modalities to include telephone and virtual monitoring.

Assists with the navigation of health care systems and intervenes or refers as needed to facilitate the achievement of patient outcomes.

Enhances patient self-management by providing information regarding all options, choices, and resources. Provides care, respecting patient personal values, culture, and belief system.
Actively participates in care delivery with priority attention to patient preference.
Provides and promotes patient-driven care in a safe, efficient, and cost-effective manner using evidence-based principles.
Utilizes approved protocols and guidelines to facilitate autonomy in providing care.
Promotes cost-effective use of resources, effective least expensive strategies expected in nonface-to-face approaches (including telehealth)
Maintains privacy and confidentiality of all patient information including electronic, print, and conversations.
Serves as a resource for patient and family rights, responsibilities, and decision-making information and processes.
Applies skills, such as motivational interviewing to promote self-management toward patient-driven holistic care plan for life manner.
Provides age and population-specific care and education.
Promotes health promotion and risk reduction strategies.
Guides others in the recognition of and participation in the resolution of ethical issue.

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

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:
Monday-Friday, 7:30am-4:00pm

Telework:
Not available

Virtual:
This is not a virtual position.

Relocation/Recruitment Incentives:
Not Authorized

Permanent Change of Station (PCS)
:
Not Authorized

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