The HCC RN Care Manager must be self-motivated, organized, flexible, responsible, and empathetic. The HCC RN Care Manager must possess and demonstrate excellent critical thinking skills and excellent nursing assessment skills. The RN is responsible for assessing and continually reassessing the needs of veterans and caregivers. The HCC RN Care Manager provides initial and continued assessment of nursing needs of the patients, evaluate cardiopulmonary status of patients, teaches the patients and caregivers effective and efficient ways of managing and delivering care in the home monitors the patients' condition and the care provided in the home, provides direct nursing care - to include but not limited to: wound care and IV administration in the home, extensive patient teaching. The incumbent provides care management and care coordination for the HCC patient, monitors the patients' nutritional, psychological, and physical status. The HCC RN Care Manager demonstrates ability to clearly narrate patient assessments to the physician: assess heart and lung sounds, hemodynamic status, assess for edema, GI/GU assessment, wound assessments with the intent of assisting the Veteran to transition to ongoing longitudinal care in PACT or HBPC (as appropriate). The HCC RN Care Manager demonstrates proficiency in computer skills (CPRS, VISTA) as all documentation is completed through a computerized patient record system. The RN is responsible for delegating and supervising the care by licensed vocational nurses and health technicians, if applicable. The RN functions as a Case Manager for the HCC enrolled Veterans and is responsible for: assessing and continually reassessing the needs of veterans and caregivers, delivering nursing care in the home, delegating and supervising the care by LPNs or vocational nurses, and home health technicians, if applicable. Major duties and responsibilities include, but are not limited to: Demonstrated clinical competencies in such areas as age-specific care, cultural assessment, and health education. An ability to effectively function autonomously, as well as a member of an interdisciplinary team Respect for cultural and spiritual values. A commitment to discipline-specific standards of practice, including: ethical conduct, the primary care delivery model, chronic disease management, palliative care, principles of care management, a holistic framework of practice, and geriatric care skills (including infection control, equipment and environmental safety). Determine the appropriateness of patients for admission into the HCC Program. Help develop patient treatment plans based on a comprehensive interdisciplinary assessment of the patient and the caregiver. Work Schedule: Monday - Friday, 8:00 am - 4:30 pm NOTE: Shifts may include weekends depending on patient care needs. Financial Disclosure Report: Not required
Internal Number: 599076000
About Veterans Affairs, Veterans Health Administration
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.