The RN Care Manager uses the nursing process and evidence-based practice to collaborate with the Teamlet (Veteran, Provider, RN Care Manager, Clinical Associate and Clerical Associate) and expanded Team (Family/Caregiver, Social Worker, Pharmacist, Dietician, Internal and Community-Based Services involved in providing care to the patient) in developing the patient driven care plan. The RN Care Manager is a member of the PACT. Major duties and responsibilities include, but are not limited to: Collaborates with services internal and external to the VA to facilitate care transition in order to effectively meet the patients' needs. Provides patient and family health education with a focus on self-management, prevention, and wellness, based on the patient's goals. T Serves as an advocate for patients, and a team leader with colleagues as she/he continues to enhance his/her own and the team's professional growth, development and practice. Performs symptom identification and triage and provides patient and family health education with a focus on self-management, prevention, and wellness, based on the patient's goals. Works in partnership with an assigned panel of patients and teamlet members for effective disease and chronic care management. Documents observations, assessments, and changes in patient's condition. Uses the nursing process (assessment, diagnosis, outcome identification, planning, implementation and evaluation) and accurately document care of Veteran patient. Work Schedule: Monday - Friday, 8:00 AM - 4:30 PM Telework: Available Virtual: This is not a virtual position. Functional Statement #: FS2686A to FS2690A Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized PCS Appraised Value Offer (AVO): Not Authorized Financial Disclosure Report: Not required
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.