Registered Nurse - Home Telehealth Case Manager/Care Coordinator - EDRP Authorized

Summary

The Incumbent is responsible and accountable for all elements of the nursing process when providing and/or supervising direct patient care. Assumes responsibility for the coordination of care focused on patient education, self-management, and customer satisfaction throughout the continuum of care.

Duties

["Duties Include: Executes position responsibilities that demonstrates leadership, experience, and creative approaches to the management of complex patient care. 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. Incumbent 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. 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. identifies patients' knowledge, health factors, skills, and behaviors that support self-management and identify gaps 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. 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 Work Schedule: Monday - Friday, 8:00am-4:30pm or 7:30am - 4:00pm Telework: Adhoc Eligible Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized EDRP Authorized: Former EDRP participants ineligible to apply for incentive. Contact VHA EDRP Program Support, the EDRP Coordinator for questions/assistance. Learn more Permanent Change of Station (PCS): Not Authorized"]

Qualifications

Basic Requirements: English Language Proficiency. In accordance with 38 U.S.C. 7403(f), no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English. Graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE); OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program. Upon achievement of a State license, the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program. (Reference VA Handbook 5005, Appendix G6); OR In cases of graduates of foreign schools of professional nursing, possession of a current, full, active, and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program. Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD). Current, full, active, and unrestricted registration as a graduate professional nurse in a State, Territory or Commonwealth (i.e., Puerto Rico) of the United States, or the District of Columbia. Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements, but do not possess the required licensure, may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.) NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification. Grade Determinations: The following Scope, Education and Dimension criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade. The Dimension requirements (Practice, Veteran/Patient Driven Care, Leadership, Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: https://apply.usastaffing.gov/ViewQuestionnaire/13106438. Grade/Level Scope Education Nurse I, Level I Delivers fundamental, knowledge-based care to assigned clients while developing technical competencies. An Associate Degree (ADN) or Diploma in Nursing, with no additional professional nursing required. Nurse I, Level II Demonstrates integration of biopsychosocial concepts, cognitive skills and technically competent practice in providing care to clients with basic or complex. An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I, Level 1 ;OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required. Nurse I, Level III Demonstrates proficiency in practice based on conscious and deliberate planning. Self-directed in goal setting for managing complex client situations. An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I, Level 2; OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I, Level 2; OR a Master's degree in nursing (MSN) and no additional professional nursing experience; OR a Master's degree in a *related field with a BSN and no additional professional nursing experience. Nurse II Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others. A BSN with 2 years of professional nursing equivalent to Nurse I, Level 3; OR an MSN with one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Master's degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Doctoral degree in Nursing with no professional nursing experience; OR a Doctoral degree in a *related field with a BSN with no additional professional nursing experience. Nurse III Executes position responsibilities that demonstrate leadership, experience and creative approaches to management of complex client care beyond the immediate practice setting. MSN and 2 years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Master's degree in *related field with BSN and two years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III. *Note: Foreign education programs/degrees are not creditable as related degrees. Applicants pending completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. Preferred Experience: 3-4 years of professional nursing experience in case management, care coordination, disease management, or a related clinical program, preferably serving Veterans or other high-risk populations. Experience providing remote patient monitoring, home telehealth, telehealth nursing, or telephone/video-based clinical care, including assessment and follow-up of patients in their homes or other nonclinical settings. Demonstrated experience monitoring, trending, and responding appropriately to vital signs, biometric data, symptoms, and disease management alerts within established clinical protocols. Experience caring for patients with complex chronic conditions, post-acute care needs, or risk for hospitalization or institutional long-term care, including development and implementation of individualized care plans. Demonstrated ability to provide patient education, health coaching, self-management support, and motivational communication to promote adherence, improve outcomes, and reduce avoidable emergency department visits and hospitalizations. Experience collaborating with interdisciplinary teams, primary care teams, specialty services, patients, families, and caregivers to coordinate services,communicate changes in clinical status, and support timely interventions. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. Physical Requirements: A pre-placement examination will be required to be able to determine if the incumbent is able to safely operate a Government-owned Vehicle.