Registered Nurse Care Manager (RNCM) Patient Aligned Care Team (PACT)

Summary

This is a Registered Nurse for the Patient Aligned Care Team (PACT). He/she provides care coordination for veterans who are assigned to a Patient Aligned Care Team (PACT) for the Shavano Park Outpatient Clinic.

Duties

Coordination of care and services for veterans that includes but is not limited to veterans with chronic disease, veterans with limited functional status, complex medical, psycho-social and/or mental health needs, severely-injured service members and veterans, and veterans with intensive continuing care needs that will require coordination of and referrals to various levels of care. The incumbent begins the coordination process at the time the patient is identified and works collaboratively with staff within the Patient Aligned Care Team as well as staff throughout the Veterans Health Administration (VHA) facility that may also be involved in his/her care, staff from other VHA facilities, Military Treatment Facilities, and referring facilities/community agencies. The Care Coordinator completes an assessment of functional status, acuity level, prognosis, and assesses the need for treatment services and resources. He/she initiates contact with the veteran and/or caregiver to assist and ensure best clinical outcomes, quality of life, and a seamless transition between facilities and levels of care. He/she monitors veteran's status and health services use while the veteran is receiving care from the PACT. The incumbent communicates and collaborates with the Interdisciplinary Team to develop and coordinate the treatment plan for veterans in the inpatient or outpatient setting. The incumbent, in collaboration with the Interdisciplinary Team, is responsible for coordinating performance improvement initiatives and for collecting relevant data required for and ensuring Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) standards. He/she provides appropriate care for the veterans ranging in age from 18 through the geriatric years, taking into consideration diagnosis and physical, psychosocial, spiritual, cultural, environmental and social support needs. Excellent customer service and communication skills are required. Duty hours and locations may change depending upon the needs of the clinic. · Leads huddles and team meeting with PACT team (LVN, Primary Care provider, MAS/clerk) · Triage unscheduled veterans, perform EKGS, SNELL vision tests, accuchecks, diabetic foot exams · Telephone triage · Maintain database/registries of high risk patients. · Enter approved consults · Promote non face to face care- scrubbing appointment list · Call patients two days after discharge from hospital or ED. · Identify high risk patients using CAN scores, DataMart, PACT Compass. · Oversee the practice of the LVNs · Function as clinic charge nurse on rotating basis - prepare schedule, adjust staffing etc. · Participate in PACT and hospital committees. · Patient Education · Women's health protocols · Follow PC/PACT policies and Procedures. 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: 7:00a.m. to 3:30p.m. or 8:00am to 4:30pm, Monday-Friday (Duty Station and hours may change due to needs of the clinic) Telework: Ad-hoc Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Bargaining Unit Status: This position is part of the bargaining unit.

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/13072970. 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