The individual provides direct nursing care to individual and groups of patients under the guidance and direction of CBOC Nurse Manager and Assistant Nurse Manager. The RN Care Manager provides care coordination and management to adult patients, aged 18-85 and older, who have chronic health conditions including hypertension, diabetes, respiratory disease, arthritis, cardiovascular disease, cancer and substance abuse. Duties include but are not limited to: Provides a full range of nursing care to patients, assuming responsibility and accountability for nursing actions. Completes initial assessments and reassessments of patient condition and response to treatment and other clinical findings. Initiates follow-up as needed. Assesses patient's learning needs, learning preference and readiness to learn, develops and implements a plan to meet needs, and instructs patients and families. Utilizes the computer to access medical information and document assessment, interventions, and outcomes. Promotes continuity of care through developing an individualized plan of care in collaboration with the patient and the interdisciplinary team. Utilizes Clinical Video Telehealth equipment to facilitate primary care remote visits Assesses patient and family learning needs, instruct patient and family on self-care, disease prevention, health promotion, exit interview activities taking into account issues related to patient's age and cultural diversity concerns related to religion, ethnic background or other issues. Work Schedule: Work Schedule: 7:30AM-4:00PM or 8:00AM-4:30PM Monday-Friday Compressed/Flexible Schedule: Not Available Virtual: Not a virtual position Functional Statement Title: Registered Nurse Care Manager, Patient Aligned Care Team, VN-610 Relocation/Recruitment Incentives: Not Authorized Financial Disclosure Report: Not Required
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.