The Registered Nurse (RN) Care Manager is responsible for organizing and directing team members to achieve desirable patient outcomes through day-to-day and/ or telephonic case management. The RN functions in the Primary Care Clinic which utilizes a Patient Aligned Care Team (PACT) model. The RN uses the nursing process and evidence-based practice to collaborate with the Core Team in developing the patient-driven care plan. Duties include but not limited to: Demonstrates clinical knowledge in assessing, planning, implementing documenting and evaluating care for a designated group of patients across the continuum of care. Triage and apply a collaborative team approach in identifying, analyzing and resolving patient care problems. Collaborates with patients to assess and identify needs, issues, care goals and resources in critical factors for achieving desired outcomes for discharge, post hospital recovery and health maintenance/wellness. Maintains current knowledge of multidisciplinary resources, programs and services, referring patients for community resources as appropriate. Utilizes problem-solving methodologies and advances clinical knowledge to resolve system and/or processes that impact patient care. Assists with navigation of health systems and intervenes or refers as needed to facilitate the achievement of patient outcomes. Provides care, respecting patient's personal values, cultural and belief systems. Assists with the development, assessment, and monitoring/ evaluation of comprehensive plans of care to ensure efficient, effective, and coordinated care in meeting and promoting standards of wellness. Coordinates an interdisciplinary approach to assure physical, psycho-social, and environmental needs and resource delivery to achieve patient goals. Work Schedule: Monday-Friday, 8:00am to 4:30pm. Tour of duty to be determined upon hire. Financial Disclosure Report: Not required Pay: Competitive salary, regular salary increases. Paid Time Off: Annual leave at the rate of eight (8) hours per biweekly pay period; Sick leave at the rate of four (4) hours per biweekly pay period; 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. Recruitment Incentive/Relocation Incentive/EDRP: not authorized for this position.
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.