Nurse (Case Manager/Home Health)

Department of Veterans Affairs

Responsible and accountable for all elements of the nursing process when providing 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. Follows procedures per established policies and guidelines. Influences care outcomes by collaborating with interdisciplinary team members.

• VA offers a comprehensive total rewards package: VA Nurse Total Rewards Listed duties are at the Full Position Level III. Functions or Scope of Assigned Duties include, but are not limited to: The Nurse Acute Care Case Management (CM) Registered Nurse (RN) executes position responsibilities that demonstrate leadership, experience, and creative approaches in providing complex patient management. Provides patient management, care coordination, and discharge/disposition planning for inpatient and outpatient settings. The CM RN assists Veterans, family members, and caregivers with receiving the most appropriate options and services to meet their complex health care needs. This includes, but is not limited to, acute, chronic, multiple, complex, catastrophic, or life-threatening illnesses; combat stress, residuals of traumatic brain injury; community adjustment; addictions and other health problems. Coordinates care with multiple providers across all levels and sites of care. The CM RN addresses psychosocial, as well as nursing and medical needs of patients and their families/caregivers, through participation in interdisciplinary patient care management practice. The CM RN also evaluates care and outcomes to ensure timely and appropriate provision of services. Demonstrates performance and leadership that is broad enough to improve the care for a group of patients. Supports colleagues and other nurses through CM knowledge sharing to provide safe, quality nursing care. Fosters a safe and supportive environment conducive to the professional development of health care professionals. Evaluates CM outcomes of evidence-based decisions and practice changes for individuals, groups, and populations. Responsible for the documented CM outcomes at the program or service level. Provides initial and ongoing assessment of patients to identify needs, issues, resources, and care goals, and identifies resources and critical factors for achieving desired outcomes for discharge, post-hospitalization recovery, and health maintenance/improvement. Responsible for delivery of quality care by using case management functions such as assessment, intervention, evaluation, and safe discharge planning, including appropriate documentation. Screens patients within 24-48 hours of admission, utilizing data from standardized sources to identify the appropriate intensity of case management required. Prioritizes the patients in need for case management. Screens patients for social service, home care, and other community care needs; and coordinates or makes referrals as appropriate; and seeks consultation when indicated. Develops Interdisciplinary Treatment Plan with measurable and objective goals, in collaboration with the patient, family, provider, and members of the interdisciplinary care team for all patients identified requiring complex level of case management. Works collaboratively with the interdisciplinary groups in a cohesive manner. Appropriately documents interventions and oversees appropriate health team documentation of patient care. Able to access and interpret patient data gathered during patient rounds. Actively participates in interdisciplinary team meetings and is competent in documenting in the GUI, VISTA, and CPRS systems about the patient's social, emotional, mental health, and medical needs. Collaborates with all the interdisciplinary members of the team, including physicians, nurses, social workers, Utilization Management team, Extended Care teams, and VA CLC staff, for program development, quality care, and resource planning. Keeps the interdisciplinary team aware of the progress, plan, and barriers. Conducts daily reviews of all the assigned patients' records for utilization management by using the InterQual Guidelines and documenting the criteria under the National Utilization Management Integration (NUMI) program mandated at the VA National level. Complete annual training in Acute Adult and Behavioral Health and achieve a passing score of 80% or higher passing (80%) of yearly Optum InterQual Competency test. Advocates fiscal responsibility in the management of patient care through effective utilization of resources. Other Duties as assigned 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-year 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 U.S. state or territory Work Schedule: M-F 7:00 am - 3:00 pm or as determined by the supervisor. Compressed/Flexible: This may be authorized at the supervisor's discretion. Telework: Not Available Virtual: This is not a virtual position

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