Registered Nurse - Patient Aligned Care Team

<p>The Registered Nurse Care Manager (RNCM) is responsible for organizing and directing team members to achieve desirable patient outcomes through day-to-day and/ or telephonic case management. The RNCM functions in the Primary Care Clinic which utilizes a Patient Aligned Care Team (PACT) model. The RNCM uses the nursing process and evidence-based practice to collaborate with the Core Team in developing the patient-driven care plan.</p><h3>Major Duties</h3><p>Duties include, but are not limited to: Demonstrates clinical knowledge in assessing, planning, implementing documenting and evaluating care for a designated group of patients across the continuum of care. Triage and apply a collaborative team approach in identifying, analyzing and resolving patient care problems. Collaborates with patients to assess and identify needs, issues, care goals and resources in critical factors for achieving desired outcomes for discharge, post hospital recovery and health maintenance/wellness. Maintains current knowledge of multidisciplinary resources, programs and services, referring patients for community resources as appropriate. Utilizes problem-solving methodologies and advances clinical knowledge to resolve system and/or processes that impact patient care. Assists with navigation of health systems and intervenes or refers as needed to facilitate the achievement of patient outcomes. Provides care, respecting patient's personal values, cultural and belief systems. Assists with the development, assessment, and monitoring/ evaluation of comprehensive plans of care to ensure efficient, effective, and coordinated care in meeting and promoting standards of wellness. Coordinates an interdisciplinary approach to assure physical, psycho-social, and environmental needs and resource delivery to achieve patient goals. 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, 7:30am - 4:00pm Compressed/Flexible: Telework: Adhoc Only, At the discretion of the hiring manager 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.<h3>Education</h3>Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html. Note: The National League for Nursing Accrediting Commission/NLNAC changed its name to ACEN in May 2013. ACEN's website may be utilized to verify accredited programs using automated inquiry processes; however, for verification of any nursing program's accreditation prior to 1998, an automated inquiry cannot be used and ACEN must be contacted directly via their email contact information on the ACEN website to verify. Note: In order to grant credit towards an appointment based on foreign nursing education higher than the associate degree level, formal degree equivalency validation from a recognized degree equivalency evaluation agency accepted by VA such as the International Consultants of Delaware (ICD) must be obtained.