Duties

The VA Midwest Health Care Network advocates for a Whole Health System of care in each of the Medical Centers. This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest. As an employee operating in a Whole Health System of care, you will operate in a model with three core elements, seeking to create a personalized health plan for each Veteran. This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community. This aligns with the Veterans Health Administration (VHA) Mission Statement to Honor America's Veterans by providing exceptional health care that improves their health and well-being.

The Patient Aligned Care Team (PACT) Care Manager RN uses the nursing process and evidence-based practice to collaborate with the Core Team (Patient, Primary Care Provider (PCP), RN Care Manager, Clinical Associate, Clerical Associate, PACT neighbors), and Expanded Team (family/caregiver, internal, and community-based services involved in providing care to the patient) in developing the patient-driven holistic care plan for life. RN utilizes the PACT Almanac, Compass, Quality Metric Report, other data sources, and Population Health Management principles to drive panel management. Triages and applies a collaborative team approach in identifying, analyzing, and resolving patient care problems. Monitors patients at high risk for hospitalization (including CAN scores of patients on panel) and keeps PCP apprised of clinical issues needing provider intervention. Monitors high-risk, high-volume, and problem-prone patients throughout their lifespan. Provides post-discharge and emergency room telephone calls to teamlet panel to ensure transition, assess current needs, and appoint as needed for follow-up care. The RN Care Manager is responsible for collaborating with services internal and external to the VA to facilitate care transition in order to effectively meet the patients' needs. The RN Care Manager provides patient and family health education with a focus on self-management, prevention, and wellness based on the patient's goals. Supports implementation of group and shared medical appointments to meet the needs of the patient panel. Applies skills, such as motivational interviewing, to promote patient self-management toward person-driven holistic care plan of life. The RN Care Manager demonstrates leadership by serving as an advocate for patients and team player to colleagues, as incumbent continues to enhance their own and the team's professional growth, development, and practice. The RN will consistently demonstrate technical skills as well as comprehensive knowledge of the program, which incumbent coordinates without the need for supervision. The RN will provide direct patient care in the clinic to include nursing driven visits and may be required to cover other areas or other PACT case managers as needed/requested.

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: Monday through Friday; 8:00 am - 4:30pm
Telework: Not Available
Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required