OUR MISSION: To fulfill President Lincoln's promise - "To care for him who shall have borne the battle and for his widow, and his orphan" - by serving and honoring the men and women who are America's Veterans. How would you like to become a part of a team providing compassionate care to Veterans? The Registered Nurse -Primary Care RN Care Manager will perform duties and responsibilities as follows: Coordinates visits according to the needs and abilities of the patient. This could include procedures, lab visits, face-to face visits, consults, patient education, telephone visits. Links patients with services and resources to benefit their care. Reviews lab work, consults, and progress notes; and completes a physical assessment to prepare for further discussion with the team provider. Assesses patients in an effort to problem solve patient care issues. Assists the clinic, as needed. Monitors Coumadin clinic. Applies appropriate nursing standards. Completes post-Emergency Department (ED)/Urgent Care and post-discharge phone calls within 2 business days, and documents results in patient's medical record. Actively manages a high risk registry which includes patients with elevated HgbA1C, hypertension, elevated LDLs, frequent hospitalizations/admissions, frequent visits to the ED/Urgent Care area, and those who are considered, by the team, to be at high risk for injury. Provides face to face follow-up visits with patients who recently visited the ED or were recently discharged. Completes all required documentation and clinical reminders. Assesses needs of the unscheduled patient visitor to the clinic. Identifies patients for and updates team high risk registry utilizing applicable Care Management templated note according to diagnosis being monitored. Participates in team huddles and interdisciplinary team meetings. Attend PACT related meetings and orient new staff to the PACT model. Obtains and reviews patient medical records from the community. Communicates plan with patient, family member and/or surrogate. Work Schedule: 7:45 a.m. - 4:15 p.m. Monday - Friday Telework: Not available. Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not authorized. Permanent Change of Station (PCS): Not authorized. Financial Disclosure Report: Not required. Physical Requirements: The population of male and female Veterans served ranges from the adult, age 18, to the elderly adult, age 65 and over. This position requires visual acuity, keen hearing, clear distinctive speech, and manual dexterity. This position requires potentially long periods of continued walking, standing, stooping, sitting, bending, pulling, and pushing. Transferring patients and objects may be required. The incumbent may be exposed to infected patients and contaminated materials and may be required to don protective clothing in isolation situations or operative/invasive procedures. The incumbent may occasionally be exposed to patients who are combative secondary to delirium, dementia, or psychiatric disorders. The incumbent must be a mature, flexible, sensible individual capable of working effectively in stressful situations, able to shift priorities based on patient needs.
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.