Summary
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 education, self-management, and customer satisfaction throughout the continuum of care.
Duties
Duties include but not limited to: Remote Patient Monitoring (RMP) Home Telehealth (HT) Registered Nurse (RN) Care Coordinator executes position responsibilities that demonstrates leadership, experience, and creative approaches to the management of complex patient care. Care will be provided in the least restrictive, most cost-effective manner. HT is a program that applies care and case management principles to coordinate care using health informatics, disease management and HT technologies to facilitate access to care and to improve the health of Veterans with the specific intent of providing the right care, in the right place, at the right time. The HT RN works to improve clinical outcomes and access to care while reducing complications, hospitalizations, and clinic or emergency room visits for Veterans in post-acute care settings and high-risk patients with chronic and mental health disease. Provides initial and ongoing comprehensive assessment to include a review of systems which establishes a comprehensive plan of care. Triages and assesses all data received from HT patients such as vital signs, reported symptoms and question responses. Identifies and intervenes for potential exacerbations of complications to facilitate timely care in Patient Aligned Care Team (PACT) clinic, Emergency Department (ED)/Urgent Care (UC), and or/care in the community. The HT RN provides communication and data exchange with community-based providers when there is co-managed care. Provides interdisciplinary consultation and interventions such as with Home Based Primary Care (HBPC) and other non-institutional care programs and venues, Mental Health (MH), Social Work (SW), Pharmacy, Nutrition, etc. The HT RN identifies patients' knowledge, health factors, skills, and behaviors that support self-management and identify gaps therein. Provides health care coaching, patient education, and motivational counseling. Communicates and facilitates with the interdisciplinary team regarding progress to goals; patterns or trends of data, symptoms or findings; concerning findings; need for provider assessment and/or interventions. Provides peers with informal constructive feedback for improvement. Fosters a safe and supportive environment conducive to the professional development of healthcare professionals. Contributes professional nursing perspective in discussions with the interdisciplinary team. Partners with others to effect change and produce optimal outcomes. Supports colleagues through knowledge sharing to provide safe, quality nursing care. Shares educational findings, experiences, and ideas with peers. Questions clinical practices for the purpose of providing evidence-based care. Participates in activities and strategies to sustain evidence-based-practice. Work Schedule: 07:00 -1530 Telework: Ad-hoc at Supervisors discretion Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not authorized Permanent Change of Station (PCS): Not authorized 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
Requirements
U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. Selective Service Registration is required for males born after 12/31/1959. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical evaluation/examination. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). You may be required to serve a probationary period. Complete all application requirements detailed in the "Required Documents" section of this announcement.
How you will be evaluated
IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, resume, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment. NOTE: Candidate's education, scope, and length of nursing practice (experience) will be considered in determining the grade and salary of the applicant selected. The recommended salary may be at any point in the range listed for this vacancy. Experience as an RN will be evaluated to determine if the experience is of an acceptable level of quality with regard to the following five dimensions of nursing: Practice, Veteran/Patient Driven Care, Leadership, Professional Development, and Evidence/Based Practice/Research. Each dimension of practice has criteria that demonstrate essential core competencies for VHA Nursing Personnel. Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience. The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position. It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment. Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.