Nurse (Care Manager), PACT

4 weeks ago

Klamath Falls, United States Veterans Health Administration Full time

Summary

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.

Duties

The incumbent is assigned to the Primary Care Service Line. Duties include, but not limited to: Responsible and accountable for all elements of the nursing process when providing and/or supervising direct patient care. Assesses, plans, implements and evaluates care based on age-specific components. Assumes responsibility for the coordination of care focused on patient transition through the continuum of care, patient and family education, patient self-management after discharge, and supporting factors that impact customer satisfaction. Considers all characteristics of the individual, including age and life stages, state of health, race and culture, values, and previous experiences. Administers medications and procedures per established policies and guidelines. Influences care outcomes by collaborating with members of the interdisciplinary team. Core elements of performance include knowledge and active participation in unit/program level quality improvement processes and initiatives as well as customer service programs Manages a designated panel of patients and utilizes VA developed protocols to manage chronic diseases working at the top of their license and within scope of practice including HTN, DM, COPD, CHF, and HLD. Perform complex, systematic nursing assessments, which include bio/psycho/social status of the Veteran and assist in the development of comprehensive treatment plans in coordination with interdisciplinary team members Develop appropriate goals in collaboration with the Veteran, participate in the evaluation of progress toward goals accomplishment and make adjustments to the treatment plan and interventions based on changing needs and response to interventions Demonstrate professional clinical judgment, including knowledge of chronic disease states, as an inherent competency applied in daily interactions with Veterans - Utilizes facility databases related to PACT and panel management processes to identify those Veterans who will benefit from chronic disease management (examples Include PACT Profile, ACSC, eQM, Primary Care Almanac, Collaborates with other service lines and community agencies through coordination of care or referral for identified Veterans with complex medical needs Conducts appointments in face to face, telephone and VA Video Connect clinics Participates in panel management and scrubbing - Triages walk-in/urgent visits and utilizes RN protocols to assist with triaging Manages secure messages assigned to RN - Conducts follow up calls for ER visits and hospitalizations (48-hour post discharge) Utilizes Health Coaching and Motivational interviewing to partner with Veterans and assist with behavior change and guidance toward his/her goals. Participates in improvement processes within scope of role (this includes EPRP, SAIL and Joint Commission readiness) Other duties as assigned.
VA offers a comprehensive total rewards package:

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, 8am- 4:30pm
Compressed Schedule: Available at the discretion of the supervisor and needs of the service
Telework: Ad-Hoc only, as determined by the agency policy.
Recruitment Incentives: May be authorized for highly qualified candidates
EDRP Authorized : Education Debt Reduction Program (loan forgiveness) - Learn more at
Permanent Change of Station (PCS) : Not Authorized
Financial Disclosure Report: Not required

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