Registered Nurse-Patient Aligned Care Team

3 weeks ago

McAllen, Texas, United States Veterans Health Administration Full time

  • Provides patient and family health education with a focus on selfmanagement, prevention, and wellness, based on the patient's goals.
  • Follows the patient's personalized health care plan as designated by the patient and Patient Aligned Care Team (PACT).
  • Demonstrates advanced clinical knowledge in assessing planning, implementing, documenting, and evaluating care for a designated group of patients across the continuum of care
  • Triages and applies a collaborative team approach in identifying, analyzing, and resolving patient care problems.
  • Time management skills and excellent communication skills which enhance the nurse's ability to effectively work with others to facilitate the daytoday mission of the clinic.
  • Patients are to be triaged in a timely manner within 45 minutes of check in time and appointment is to be completed within 30 minutes.
  • Provides indirect patient care in collaboration with the interdisciplinary team; serves as clinical resource expert; and functions as an educator for the team and patient.
  • Functions as a systems coordinator; monitors progress and intervenes as necessary to ensure that patient outcomes are achieved within anticipated timeframes. Monitors progress along clinical pathways, analyzes variations and initiates appropriate actions.
  • Is a role model in the provision of excellent customer service.
  • Reviews Message Manager and assist Team to address/complete pending alerts communicated throughout tour of duty to facilitate care and address needs of the caller within 48 hours.
  • Completes and documents Nursing Notes in CPRS, as applicable, in a timely manner and closes the Encounter Notes for patients not seen by a provider. Notes will be closed by the end of tour of duty daily.

Areas to be addressed include:

Encounters:
reasons for visit-Service Connection; Primary assignment-Service connected conditions under the Diagnosis tab; Procedures, ACSC conditions, etc.

  • Completes all clinical reminders that may be completed by the RN or LVN prior to the due date.
  • Provides Care Management to patients with Ambulatory Care Sensitive Conditions (ACSCs) including reviewing the patient record, decide if the patient needs more indepth education (formal and/or informal); nursing visits and/or telephone calls between provider visits to assist in care management. Collaborates with the High Risk Care Coordinators, Home Telehealth, social work, and/or dieticians for referrals and care management.
  • Complete the Blood Glucose meter check daily, as applicable. After completing quality check, if applicable, and entering correct patient information for testing.
  • Completes and documents secure messaging within 72 hours. Surrogate is identified at all times. Escalation of secure messaging must be maintained at 10% or less. Diverts messages to appropriate care lines as needed. Alerts MyHealtheVet coordinator for assistance to prevent incomplete or escalation of messages.
  • Provides patients with personalized, proactive, and patientdriven health care through such activities as assisting in developing a personal health plan, listening to the patient and addressing their needs/goals, engaging in group appointments, encouraging and supporting Telehealth modalities, and creating an environment that benefits the veteran.
  • Delivers patient centered care to all patients and employs population health management principles to optimize health and wellbeing for the patient through such activities as use of evidencedbased practice recommendations, completing clinical reminders, tracking high risk behaviors, maintains an awareness of access with an awareness of third next available appointments and assisting the patient to develop coping mechanisms, assisting the patient to identify health care goals and actions to take to meet those goals and evaluating progress.
  • Actively educates the patient and family on health promotion and disease prevention strategies and options for care and treatment.
Other duties as assigned

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, 08:00am-04:30pm

Telework:
Available Ad Hoc Only

Virtual:
This is not a virtual position.

Relocation/Recruitment Incentives:
Not Authorized

Permanent Change of Station (PCS): Not Authorized

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