Registered Nurse Care Manager (RNCM) Patient Aligned Care Team (PACT)

Department of Veterans Affairs

This is a Float Registered Nurse position for the Patient Aligned Care Team (PACT). This position covers multiple Outpatient Clinics at South Texas Veterans Healthcare System. The incumbents home base clinic will be Balcones Heights Outpatient Clinic but will be required to travel to other Outpatient Clinics depending on their staffing needs.

• These clinics include North Central Federal Clinic, North Bexar, Northeast Bexar, Shavano Park, IMC, South Bexar, Specialty Care and Northwest Healthcare Center. Coordination of care and services for veterans that includes but is not limited to veterans with chronic disease, veterans with limited functional status, complex medical, psycho-social and/or mental health needs, severely-injured service members and veterans, and veterans with intensive continuing care needs that will require coordination of and referrals to various levels of care. The incumbent begins the coordination process at the time the patient is identified and works collaboratively with staff within the Patient Aligned Care Team as well as staff throughout the Veterans Health Administration (VHA) facility that may also be involved in his/her care, staff from other VHA facilities, Military Treatment Facilities, and referring facilities/community agencies. The Care Coordinator completes an assessment of functional status, acuity level, prognosis, and assesses the need for treatment services and resources. He/she initiates contact with the veteran and/or caregiver to assist and ensure best clinical outcomes, quality of life, and a seamless transition between facilities and levels of care. He/she monitors veteran's status and health services use while the veteran is receiving care from the PACT. The incumbent communicates and collaborates with the Interdisciplinary Team to develop and coordinate the treatment plan for veterans in the inpatient or outpatient setting. The incumbent, in collaboration with the Interdisciplinary Team, is responsible for coordinating performance improvement initiatives and for collecting relevant data required for and ensuring Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) standards. He/she provides appropriate care for the veterans ranging in age from 18 through the geriatric years, taking into consideration diagnosis and physical, psychosocial, spiritual, cultural, environmental and social support needs. Excellent customer service and communication skills are required. Duty hours and locations may change depending upon the needs of the clinic. · Leads huddles and team meeting with PACT team (LVN, Primary Care provider, MAS/clerk) · Triage unscheduled veterans, perform EKGS, SNELL vision tests, accuchecks, diabetic foot exams · Telephone triage · Maintain database/registries of high risk patients. · Enter approved consults · Promote non face to face care- scrubbing appointment list · Call patients two days after discharge from hospital or ED. · Identify high risk patients using CAN scores, DataMart, PACT Compass. · Oversee the practice of the LVNs · Function as clinic charge nurse on rotating basis - prepare schedule, adjust staffing etc. · Participate in PACT and hospital committees. · Patient Education · Women's health protocols · Follow PC/PACT policies and Procedures. 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: 7:00a.m. to 3:30p.m. or 8:00am to 4:30pm, Monday-Friday (Duty Station and hours may change due to needs of the clinic) Telework: Ad-hoc Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Bargaining Unit Status: This position is part of the bargaining unit.

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