Registered Nurse-Coordinated Transitional Care (CTraC) Nurse Case Manager- Outpatient Staff

<p>Responsible and accountable for all elements of the nursing process when providing and/or supervising direct patient care. Assesses, plans, implements, and evaluates care based on age specific components. Assumes responsibility for the coordination of care focused on patient education, self-management, and customer satisfaction throughout the continuum of care. Influences care outcomes by collaborating with members of the interdisciplinary team.</p><h3>Major Duties</h3><p>The Coordinated Transitions of Care (CTra-C) Outpatient Staff Registered Nurse (RN) works across the healthcare system and is responsible and accountable for developing and implementing competent, evidence-based, comprehensive patient care for the adult/geriatric patient population assessing, planning, implementing, and evaluating activities and programs. The Nurse provides care management and chronic disease management. This includes managing and monitoring high risk patient for improvement of patient outcomes including prevention of hospitalization and improvement in ambulatory care sensitive conditions. The nurse collaborates and coordinates care with interdisciplinary team members from other services within the department as well as in the community. Utilizing registries and/or databases, the nurse is responsible for identifying patients that meet criteria for participation in the CTra-C program. CTra-C utilizes virtual modalities to care, primarily telephone encounters with the initial visit with the patient 1-3 days after hospital discharge for a period of 4 weeks. The nurse reviews and implements the four pillars of transitional care: 1) Identification of yellow and red zones - sign/symptoms needing medical attention; 2) Orientation of health team and who to call when yellow or red flags arise; 3) Reconciliation of medications, patient led, including all over the counter medications and supplements; and 4) Establishment/ confirmation of of clinical follow up including clinic visits, diagnostic testing, and outstanding consults during telephone follow up calls. This nurse will assist in directing the provision of nursing education, orientation, competencies, and providing quality improvement and outcomes utilization. The nurse demonstrates performance and leadership that is broad enough to improve the care for the facility level. Evaluates practice patient outcomes of evidence based decisions and practice changes for individuals, groups, and populations. 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 7:30 am - 4:00 pm Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized</p><h3>Requirements</h3>U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. Selective Service Registration is required for males born after 12/31/1959. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical examination. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). You may be required to serve a probationary period. Complete all application requirements detailed in the "Required Documents" section of this announcement.