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Registered Nurse Patient Aligned Care Team
4 months ago
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. 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
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:
Telework: Yes, Ad-hoc
Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not Authorized
EDRP Authorized: Contact , the EDRP Coordinator for questions/assistance. Learn more
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required
The RN Care Manager is a proficient nurse who demonstrates proficiency in using the nursing process in providing care for clients with complex nursing care needs. Practice is enhanced through development of collegial relationships. This nurse demonstrates collaboration by using the group process to solve problems. The focus is on conducting self-assessments of performance and is able to identify own learning needs. The proficient nurse demonstrates critical thinking with efficiency and refers to, consults with and makes provisions for continuity of care with other health care providers.
Duties include but are not limited to:
- Delivers care in compliance with state licensure statutes, Department of Veterans Affairs and the standards set forth by the Joint Commission.
- Uses the nursing process and evidence-based practice to collaborate with the Core Team (Patient, Primary Care Provider, RN Care Manager, Clinical Associate and Administrative Associate) and Expanded Team (family/caregiver, internal and community-based services involved in providing care to the patient) in developing the patient-driven holistic care plan for life.
- Responsible for collaborating with services internal and external to the VA to facilitate care transition to effectively meet the patients' needs.
- Provides patient and family health education with a focus on self-management, prevention, and wellness, based on the patient's goals.
- Demonstrates leadership by serving as an advocate for patients, team player to colleagues as she/he continues to enhance his/her own and the team's professional growth, development and practice.
- Manages and delivers care through various modalities, which include but is not limited to the currently available modalities such as face-to-face clinic visits, telephone calls, Secure Messaging and Clinical Video Telehealth (CVT) in collaboration with the team members to ensure that all patients' management /care coordination are addressed in a timely manner.
- Collaborates with the team in completing Two-Day Post Discharge from hospital and emergency room phone calls and plays an active role in post discharge visits.
- Will use VA developed tools to help identify patients that are at high risk for hospital admission from Ambulatory Care Sensitive Conditions (ACSC) and will work with the team to establish a plan of care to decrease the number of Emergency Room visits and hospital admissions. These tools include the PACT Huddle Tool and utilizing VSSC or other data sources to gather patient information to assist with plan of care development.
- Collaborates with different disciplines which include but is not limited to the currently available disciplines such as Pharmacy, Social Work, Mental Health, HUD VASH and Care in the Community to ensure goals set forth in the patient's plan of care are met.
