Registered Nurse Care Manager/Coordinator

- Uses the nursing process and evidence-based practice to collaborate with the Teamlet and larger Team (family/caregiver, internal and community-based services involved in providing care to the patient) in developing and patient -driven holistic care plan for life.
- Provides patient and family health education with a focus on self-management, 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 day-to-day 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 in-depth 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.

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: 8 - 4:30pm, Monday thru Friday
Telework: Not Available
Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized