Registered Nurse - Remote Patient Monitoring (RMP) Home Telehealth Case Manager (HT)

About the position The Remote Patient Monitoring (RMP) Home Telehealth (HT) Registered Nurse (RN) Case Manager executes position responsibilities that demonstrates leadership, experience, and creative approaches to the management of complex patient care. The RMP/HT is responsible to the Telehealth Nurse Manager. Care will be provided in the least restrictive, most cost-effective manner. HT is a program that applies care and case management principles to coordinate care using health informatics, disease management and HT technologies to facilitate access to care and to improve the health of Veterans with the specific intent of providing the right care, in the right place, at the right time. Duties include but are not limited to: Works to improve clinical outcomes and access to care while reducing complications, hospitalizations, and clinic or emergency room visits for Veterans in post-acute care settings and high-risk patients with chronic and mental health disease. Provides initial and ongoing comprehensive assessment to include a review of systems which establishes a comprehensive plan of care. Triages and assesses all data received from HT patients such as vital signs, reported symptoms and question responses. Identifies and intervenes for potential exacerbations of complications to facilitate timely care in Patient Aligned Care Team (PACT) clinic, Emergency Department (ED)/Urgent Care (UC), and or/care in the community. Provides communication and data exchange with community-based providers when there is co-managed care. Provides interdisciplinary consultation and interventions such as with Home Based Primary Care (HBPC) and other non-institutional care programs and venues, Mental Health (MH), Social Work (SW), Pharmacy, Nutrition, etc. Identifies patients' knowledge, health factors, skills, and behaviors that support self-management and identify gaps therein. Provides health care coaching, patient education, and motivational counseling. Communicates and facilitates with the interdisciplinary team regarding progress to goals; patterns or trends of data, symptoms or findings; concerning findings; need for provider assessment and/or interventions. Provides peers with informal constructive feedback for improvement. Fosters a safe and supportive environment conducive to the professional development of healthcare professionals. Contributes professional nursing perspective in discussions with the interdisciplinary team.

Responsibilities

• Improve clinical outcomes and access to care while reducing complications, hospitalizations, and clinic or emergency room visits.
• Provide initial and ongoing comprehensive assessment to include a review of systems which establishes a comprehensive plan of care.
• Triage and assess all data received from HT patients such as vital signs, reported symptoms and question responses.
• Identify and intervene for potential exacerbations of complications to facilitate timely care.
• Provide communication and data exchange with community-based providers when there is co-managed care.
• Provide interdisciplinary consultation and interventions.
• Identify patients' knowledge, health factors, skills, and behaviors that support self-management and identify gaps therein.
• Provide health care coaching, patient education, and motivational counseling.
• Communicate and facilitate with the interdisciplinary team regarding progress to goals; patterns or trends of data, symptoms or findings; concerning findings; need for provider assessment and/or interventions.
• Provide peers with informal constructive feedback for improvement.
• Foster a safe and supportive environment conducive to the professional development of healthcare professionals.
• Contribute professional nursing perspective in discussions with the interdisciplinary team.

Benefits

• Competitive salary, regular salary increases, 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
• Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)
• 1 full and unrestricted license from any US State or territory

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