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

About the role

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.

Responsibilities

• Develops and implements competent - evidence-based - comprehensive patient care for the adult/geriatric patient population.
• Assesses, plans, implements, and evaluates activities and programs.
• Collaborates and coordinates care with interdisciplinary team members from other services within the department as well as in the community.
• Identifies patients that meet criteria for participation in the CTra-C program using registries and/or databases.
• Provides care management and chronic disease management, including managing and monitoring high-risk patients for improvement of patient outcomes.
• Reviews and implements the four pillars of transitional care: identification of yellow and red zones, orientation of health team, medication reconciliation, and clinical follow-up.
• Assists in directing the provision of nursing education, orientation, competencies, and quality improvement and outcomes utilization.
• Evaluates practice patient outcomes of evidence-based decisions and practice changes for individuals, groups, and populations.

Requirements

• Basic Requirements: Graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited by one of the following accrediting bodies at the time the program was completed by the applicant: ACEN or CCNE.
• English Language Proficiency: No person shall serve in direct patient care positions unless they are proficient in basic written and spoken English.
• Current - full - active - and unrestricted registration as a graduate professional nurse in a State, Territory, or Commonwealth of the United States, or the District of Columbia.
• Certification (if not will be required within 1 year of employment).

Qualifications

• Basic Education Requirements: An Associate Degree (ADN) or Diploma in Nursing, with no additional professional nursing required.
• Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required.
• Master's degree in nursing (MSN) and no additional professional nursing experience.
• Master's degree in a related field with a BSN and no additional professional nursing experience.
• Doctoral degree in Nursing with no professional nursing experience.
• Doctoral degree in a related field with a BSN and no additional professional nursing experience.

Skills

• Knowledge of age-specific components of the nursing process.
• Ability to collaborate with interdisciplinary teams.
• Experience in acute care, PACT, case management, or chronic disease management.
• Proficiency in virtual care delivery methods.

Benefits

• Competitive salary with regular salary increases and potential for performance awards.
• 50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year).
• Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA.
• Insurance benefits including federal health/vision/dental/term life/long-term care.
• Annual Employee Health requirements, such as annual TB screening or testing.
• Work schedule: Monday - Friday 7:30 am - 4:00 pm.
• No telework or virtual options available.

Pay

Competitive salary with regular salary increases and potential for performance awards.

Schedule

Monday - Friday 7:30 am - 4:00 pm.

Application Instructions

This position does not require relocation/recruitment incentives.