The incumbent will practice as a Registered Nurse in a Patient Aligned Care Team.

Duties

The RN Care Manager uses the nursing process and evidence-based practice to collaborate with the Teamlet (Patient, Provider, LPN, and Clinical Support Technician) and larger Team (family/caregiver, internal and community-based services involved in providing care to the patient) in developing a patient-driven holistic care plan for life. The RN Care Manager is responsible for collaborating with services internal and external to the VA to facilitate care transition to effectively meet the patient's needs. The RN Care Manager provides patient and family health education with a focus on self-management, prevention, and wellness, based on the patients goals. The RN Care Manager serves as an advocate for patients, and a team player to colleagues as she/he continues to enhance his/her professional growth, development, and practice in support of the veteran and team. Demonstrates beginning skills in leadership and mastery of practice as a novice in delivering efficient, comprehensive, and continuous patient-driven holistic care through active collaboration, communication, and coordination of resources. Demonstrates clinical knowledge in assessing, planning, implementing, documenting, and evaluating care for a designated group of patients across the continuum of care: Recognizing the age-related cognitive, physical, emotional, and chronological maturation needs of adult and geriatric patients. Triages and applies a collaborative team approach in identifying, analyzing, and resolving patient care problems. Collaborates with patients to assess and identify needs, issues, care goals, and resources in critical factors for achieving desired outcomes for discharge, post-hospital recovery, and health maintenance/wellness. Maintains current knowledge of multidisciplinary resources, programs, and services, referring patients to community resources as appropriate. Demonstrates ability to collaborate with all levels of services and disciplines. Collaborates with the patient, family, and care providers in all settings where care is being provided to evaluate and update changes in the patient-driven life plan and patient management. Reviews options with patients and families, including costs, alternatives, risks/benefits, and services. Advocates fiscal responsibility through monitoring utilization of resources. Identifies high-risk populations/chronic disease tracking and patients that could benefit from CCHT, HBPC, Clinical Pharmacy, and extended team members. RN Care Managers have obtained access to databases: VSSC and Vision 11 database allowing them to identify high risk patients thru the almanac, compass, and CAN risk scores and will utilize nurse face-to-face clinics and non-face-to face modalities to include telephone and virtual monitoring. Assists with the navigation of health care systems and intervenes or refers as needed to facilitate the achievement of patient outcomes. Enhances patient self-management by providing information regarding all options, choices, and resources. Provides care, respecting patients personal values, cultures and beliefs. Actively participates in care delivery with priority attention to patient preference. Provides and promotes patient-driven care in a safe, efficient, and cost-effective manner using evidence-based principles. Utilizes approved protocols and guidelines to facilitate autonomy in providing care. Promotes cost-effective use of resources, effective least expensive strategies expected in non-face-to-face approaches (including telehealth). Maintains privacy and confidentiality of all patient information including electronic, print, and conversations. Serves as a resource for patient and family rights, responsibilities, and decision-making information and processes. Applies skills, such as motivational interviewing to promote self-management toward a patient-driven holistic care plan for life 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-Friday, 7:00am-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

Requirements

Qualifications

Basic Requirements: English Language Proficiency. In accordance with 38 U.S.C. 7403(f), no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English. Graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited 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); OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program. Upon achievement of a State license, the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program. (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 to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program. Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD). 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. Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements, but do not possess the required licensure, may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.) NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification. Grade Determinations: The following Scope, Education and Dimension criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade. The Dimension requirements (Practice, Veteran/Patient Driven Care, Leadership, Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: https://apply.usastaffing.gov/ViewQuestionnaire/12414544. Grade/Level Scope Education Nurse I, Level I Delivers fundamental, knowledge-based care to assigned clients while developing technical competencies. An Associate Degree (ADN) or Diploma in Nursing, with no additional professional nursing required. Nurse I, Level II Demonstrates integration of biopsychosocial concepts, cognitive skills and technically competent practice in providing care to clients with basic or complex. An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I, Level 1 ;OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required. Nurse I, Level III Demonstrates proficiency in practice based on conscious and deliberate planning. Self-directed in goal setting for managing complex client situations. An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I, Level 2; OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I, Level 2; OR a Master's degree in nursing (MSN) and no additional professional nursing experience; OR a Master's degree in a *related field with a BSN and no additional professional nursing experience. Nurse II Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others. A BSN with 2 years of professional nursing equivalent to Nurse I, Level 3; OR an MSN with one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Master's degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Doctoral degree in Nursing with no professional nursing experience; OR a Doctoral degree in a *related field with a BSN with no additional professional nursing experience. Nurse III Executes position responsibilities that demonstrate leadership, experience and creative approaches to management of complex client care beyond the immediate practice setting. MSN and 2 years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Master's degree in *related field with BSN and two years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III. *Note: Foreign education programs/degrees are not creditable as related degrees. 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: Light lifting (under 10 lbs.); standing and sitting, ability to sit for periods and stand, the ability for rapid mental and muscular coordination simultaneously; both eyes required; depth perception; ability to distinguish basic colors; hearing (aid permitted). Work may be performed under constant noise working with hands in water, working closely with others.

Education

IMPORTANT: A transcript, either official or unofficial, must be submitted with your application for ALL degrees. A copy of your certificate/degree or screenshot of your current classes are not a replacement of your transcript and they will not be used in the qualifying process. Transcripts must include the following information:

• Your Name
• Name of the college or university
• Full address of the college or university
• Degree Received
• Date Conferred

We cannot accept a screenshot of your classes or a picture of your degree for qualification purposes.

Note: 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/. 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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

Contacts

• Address John D Dingell Department of Veterans Affairs Medical Center 4646 John R Street Detroit, MI 48201 US
• Name: Megan Giffel
• Email: [email protected]