The PACT RN Care Manager uses the nursing process and evidence-based practice to collaborate with the Core Team (Patient, Primary Care Provider, RN Care Manager and Patient Support Technician) and Expanded Team (family/caregiver, internal and community-based services involved in providing care to the patient) in developing the patient-driven holistic care plan for life. The RN Care Manager is a member of the core team. The RN Care Manager demonstrates leadership by serving as an advocate for patients, team player to colleagues as she/he continues to enhance his/her own and the team's professional growth, development and practice. Fundamental responsibilities of the PACT RN Care Manager include the following: Duties include but are not limited to: Ongoing, continuous care of one or more assigned panel(s) of Veterans. Utilize all available tools, such as registries, to enable effective and efficient identification and intervention of individual patients and cohorts. Ensure appropriate evaluation and access is provided to patients assigned to the patient panel. Function at the full extent of the team member's relevant clinical privileges, credentials, scopes of practice, elements of practice, certification, functional statement, position description, or other VHA or local facility approved documentation of competency. Participate in team performance improvement and sustainment activities to optimize team efficiency and care delivery to patients. Implement primary care operations management processes, as appropriate. Manage communications and facilitating safe transitions of patients between the PACT's site of care and other health care settings, using informal and formal communication methods, as appropriate. Provide health education and health coaching on wellness, disease prevention, chronic care management, and self-management skills to patients and personal support persons, commensurate with the documented expertise or professional training of the PACT member. Engage patients in using health care, encouraging patients to engage personal support persons, receiving input from patients and personal support persons regarding VA care. Use formal and informal communications that are respectful, effective, timely, and bidirectional with all team members (including the patient and personal support persons) to convey significant, clinically relevant information for the care of the patient. Collaborate with informatics technology staff to develop and implement systematized, electronically supported, standardized, tools to support PACT care delivery processes (e.g., pre-visit reminder calls, post-hospitalization follow-up calls, recall scheduling procedures, new patient orientation, disease registries and primary care protocols for chronic disease management). Work Schedule: Monday-Friday; 8:00am-4:30pm Financial Disclosure Report: Not required Recruitment/Relocation Incentive: Not Authorized PCS/EDRP: Not Approved 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; 10 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 is not authorized for this position.
Internal Number: 599230900
About Veterans Affairs, Veterans Health Administration
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.