Registered Nurse - PACT Care Manager/Coordinator position is within the VA Texas Valley Coastal Bend Health Care System in Corpus Christi, TX.

Duties

Uses the nursing process and evidence-based practice to collaborate with the Teamlet and larger Team (family/caregiver, internal and community-based services involved in providing care to the patient) in developing and patient -driven holistic care plan for life. Provides patient and family health education with a focus on self-management, prevention, and wellness, based on the patient's goals. Follows the patient's personalized health care plan as designated by the patient and Patient Aligned Care Team (PACT). Demonstrates advanced clinical knowledge in assessing planning, implementing, documenting, and evaluating care for a designated group of patients across the continuum of care. Triages and applies a collaborative team approach in identifying, analyzing, and resolving patient care problems. Provides indirect patient care in collaboration with the interdisciplinary team; serves as clinical resource expert; and functions as an educator for the team and patient. Functions as a systems coordinator; monitors progress and intervenes as necessary to ensure that patient outcomes are achieved within anticipated timeframes. Monitors progress along clinical pathways, analyzes variations and initiates appropriate actions. Completes and documents Nursing Notes in CPRS, as applicable, in a timely manner and closes the Encounter Notes for patients not seen by a provider. Provides Care Management to patients with Ambulatory Care Sensitive Conditions (ACSCs) including reviewing the patient record, decide if the patient needs more indepth education (formal and/or informal); nursing visits and/or telephone calls between provider visits to assist in care management. Collaborates with the High Risk Care Coordinators, Home Telehealth, social work, and/or dieticians for referrals and care management. Complete the Blood Glucose meter check daily, as applicable. After completing quality check, if applicable, and entering correct patient information for testing. Completes and documents secure messaging within 72 hours. Surrogate is identified at all times. Escalation of secure messaging must be maintained at 10% or less. Diverts messages to appropriate care lines as needed. Alerts MyHealtheVet coordinator for assistance to prevent incomplete or escalation of messages. Provides patients with personalized, proactive, and patient-driven health care through such activities as assisting in developing a personal health plan, listening to the patient and addressing their needs/goals, engaging in group appointments, encouraging and supporting Telehealth modalities, and creating an environment that benefits the veteran. Delivers patient centered care to all patients and employs population health management principles to optimize health and wellbeing for the patient. Actively educates the patient and family on health promotion and disease prevention strategies and options for care and treatment. Advocates fiscal responsibility in the management of patient care through effective utilization of resources, to include medical supplies and non-traditional appointments. Supports patient-driven care in a safe, efficient manner, using evidence-based principles. Work Schedule: Monday - Friday, 0800 - 1630 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 Bargaining Unit Status: This position is part of the bargaining unit. 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

Requirements

Qualifications

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. BASIC REQUIREMENTS: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency: In accordance with 38 U.S.C. 7402(d), no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English. Education: Graduate of a school of professional nursing approved by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE). The approving official may authorize a waiver of the requirement for ACEN or CCNE accreditation of any degree in nursing provided the college or university has regional accreditation from an accrediting body recognized by the Department of Education at the time of the candidate's graduation and the composite qualifications of the applicant warrant such consideration. In cases of graduates of foreign schools of professional nursing, possession of current, full, active and unrestricted registration will meet the requirement of graduation from an approved school of professional nursing. OR The completion of coursework equivalent to a nursing degree in a MSN Bridge Program that qualifies for professional nursing registration constitutes the completion of an approved course of study of professional nursing. Students should submit the certificate of professional nursing to sit for the NCLEX to the VA along with a copy of the MSN transcript. (Reference VA Handbook 5005, Appendix G6) OR In cases of graduates of foreign schools of professional nursing, possession of a current, full, active and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing. License: Current, full, active, and unrestricted registration as a graduate professional nurse in a State, Territory or Commonwealth (i.e., Puerto Rico) of the United States, or the District of Columbia. Preferred Experience: Recent ambulatory care experience 1-3 years of Med Surgery/ED experience 1-3 years Recent care coordination experience 1-3 years of Outpatient care experience Tele Health nursing experience Grade Determinations: The following criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade: Nurse I Level I - An Associate Degree (ADN) or Diploma in Nursing, with no additional nursing practice/experience required. Nurse I Level II - An ADN or Diploma in Nursing and approximately 1 year of nursing practice/experience; OR an ADN or Diploma in Nursing and a bachelor's degree in a related field with no additional nursing practice/experience; OR a Bachelor's of Science in Nursing (BSN) with no additional nursing practice/experience. Nurse I Level III - An ADN or Diploma in Nursing and approximately 2-3 years of nursing practice/experience; OR an ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 1-2 years of nursing practice/experience; OR a BSN with approximately 1-2 years of nursing practice/experience; OR a Master's degree in nursing (MSN) or related field with a BSN and no additional nursing practice/experience. Nurse II - A BSN with approximately 2-3 years of nursing practice/experience; OR ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 2-3 years of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 years of nursing practice/experience; OR a Doctoral degree in nursing or meets basic requirements for appointment and has doctoral degree in a related field with no additional nursing practice/experience required. Nurse III - Master's degree in nursing or related field with BSN and approximately 2-3 years of nursing practice/experience; OR a Doctoral degree and approximately 2-3 years of nursing practice/experience. Note regarding MSN degrees: If your MSN was obtained via a Bridge Program that qualifies for professional nursing registration, a BSN is not required. Reference: VA Regulations, specifically VA Handbook 5005, Part II, Appendix G-6 Nurse Qualification Standard. This can be found in the local Human Resources Office. Physical Requirements: Moderate lifting, 15-44 pounds; Moderate carrying, 15-44 pounds; Straight pulling (0.5 hours); Pushing (0.5 hours); Reaching above shoulder; Walking (5.3 hours); Standing (5.3 hours); Repeated bending (5.3 hours); Ability for rapid mental and muscular coordination simultaneously; Near vision correctable at 13" to 16" to Jaeger 1 to 4; Far vision correctable in one eye to 20/20 and to 20/40 in the other; Depth perception; Ability to distinguish basic colors; Hearing (aid may be permitted).

Education

EDUCATION ACCREDITATION: The Associate Degree in Nursing (ADN), Bachelor of Science degree in Nursing (BSN), or Master of Science Degree in Nursing (MSN) must be recognized by the appropriate State-accrediting agency and accredited by either of the following accrediting agencies at the time the program was completed by the applicant:

1. The Accreditation Commission for Education in Nursing (ACEN) OR
2. The Commission on Collegiate Nursing Education (CCNE)
3. ACEN/NLNAC or CCNE program or degree accreditation may also be found under the U.S. Department of Education

NOTES:

• Department of Education: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/.
• Foreign Education: If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.
• School Name: If your school has changed names, or is no longer in existence, you must provide this information in your application.
• No longer on accreditation site: If your school was accredited by ACEN or CCNE at the time of graduation, but is no longer listed on the websites, you must provide documentation of accreditation with your application packet

IMPORTANT - Transcript: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.

Contacts

• Address VA TX Valley Coastal Bend HCS 2601 Veterans Drive Harlingen, TX 78550 US
• Name: VISN 17 SSU USAS Group
• Email: [email protected]