Nurse (PACT Care Manager)

4 months ago

Astoria, New York, United States Department Of Veterans Affairs Full time
Summary

The Registered Nurse (RN) assigned to the VAPORHCS Patient Aligned Care Team (PACT) Primary Care Clinic functions as the PACT Nurse Care Manager (NCM) and may be assigned to the clinics located in Astoria, Bend, Fairview, Hillsboro, Portland, Salem, The Dalles, Vancouver (WA), and West Linn.



Duties

The PACT NCM is a member of the PACT Teamlet (Primary Care Provider, Nurse Care Manager, Licensed Practical Nurse, Health Technician, and Clerical Associate) and supports the work of the expanded team (Pharmacist, Social Worker, Home Telehealth RN, Psychologist, and Dietician).

  • Identifies and provides case management for high-risk cohort of patients utilizing chronic disease management data mining tools to include but not limited to Care Management Tool (CMT), Business Intelligent Strategic Learning (BISL), VISN 20 Access Report, VISTA, and VHA Support Service Center (VSSC) reports such as PC Almanac, Compass, Primary Care Management Module (PCMM) Care Needs Assessment (CNA).
  • Utilizes other registries to manage disease processes such as Diabetic, Mammography, Cardiovascular, and Opioid Registries to access data base for pain management.
  • Performs timely Post-Discharge/ ED/ Urgent Care and Walk-ins' using appropriate documentation templates/notes, codes, education.
  • Assesses and enrolls eligible patients into nontraditional modalities of care such as Home telehealth and Telemedicine.
  • Utilizes Teach and Motivational Interviewing techniques to encourage positive health behavioral change and Health Promotion and Disease Prevention.
  • Provides patient and family education with a focus on self-management, prevention, and wellness, based on 'what matters most' to the patient.
  • Reviews, tracks, and devises strategies to improve Healthcare Effective Data Information Sets (HEDIS) metrics, clinical reminders, panel access, timely encounter closures, and other performance metrics.
  • Facilitates continuity of care by partnering with multidisciplinary services, internal and external to the Department of Veterans Affairs. Initiates and participates in various quality and process improvement activities that result in improved patient outcomes.
  • Provide VA Video Connect (VVC), Clinical Video Technology (CVT), or Telemedicine.
  • Responsible for maintaining knowledge of and skill in applying an intensive body of rules, procedures, and operations in telehealth related technologies and a variety of computer hardware/ software used in technology, data entry, retrieval, record maintenance, document, and report generation.
  • May be required to perform specimen collection of (urine, sputum, blood, or stool) ensuring to utilize proper labeling, packaging, and transport instructions from the Primary Care Community Based Clinics or assigned areas to the main facility laboratory.
  • Utilizes proper facility required patient identified methods and ensure patient confidentiality is maintained.
  • Access and complete specimen orders from the hospital computerized system, utilize centrifugation (id required), and prepare specimen prior to laboratory testing.
  • Exercises effective communication skills prior to, during, and after specimen collection, ensuring to review pertinent information with the patient.
  • Maintains specimen integrity by using aseptic techniques, following department procedures, and observing and adhering to personal protective equipment policies and guidelines.
  • Adheres to applicable infection control guidelines of hand hygiene before and after venipuncture of all patients.
  • Demonstrates knowledge, skill, and competency in venipuncture and specimen collection.
  • Resolves order discrepancies by contacting the order originator for further clarification, notifying supervisor of unresolved orders.
  • Maintains a safe and secure working environment by adhering to local medical center standards, policies, and procedures as well as other federal or state regulating bodies to include but not limited to Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), Occupational Health and Safety Administrator (OSHA), and the Center for Disease Control (CDC).
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, varying tours between

Compressed/Flexible: Not Available

Telework: VA supports the use of telework as a way to help attract and retain talented individuals in public service, increase worker productivity, and better prepare the agency to operate during emergencies. May be authorized for Ad hoc telework. Telework eligibility will be discussed during the interview process.

Virtual: This is not a virtual position.

Relocation/Recruitment Incentives: Not Authorized

Financial Disclosure Report: Not required

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