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RN - Care Manager Patient Aligned Care Team (PACT)

VA Medical Center


Location:
Pocatello, ID
Date:
01/05/2018
2018-01-052018-02-04
Categories:
  • Medical/Surgical
  • Anesthesia/CRNA
  • Long Term Care
  • LPN/LVN
  • Neurology/Neurosurgery
  • Physical Medicine/Rehabilitation
  • IV Therapy
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Job Details


Summary

OUR MISSION: To fulfill President Lincoln's promise - "To care for him who shall have borne the battle and for his widow, and his orphan" - by serving and honoring the men and women who are America's Veterans. How would you like to become a part of a team providing compassionate care to Veterans?

The VA Salt Lake City Health Care System (VASLCHCS) is made up of compassionate employees committed to caring for Veterans whose sacrifices know no limit. We are part of the Rocky Mountain Veterans Integrated Service Network (VISN 19). Our health care system consists of the George E. Whalen Utah, Idaho, and Nevada. We provide health care to over 50,000 eligible Veterans across one of the largest geographical areas in VA. We are a teaching hospital, providing full range of patient care services, holistic medicine as well as education and research in partnership with the University of Utah and other institutions of higher education. Comprehensive health care is provided through our primary care providers and tertiary care is offered in areas of medicine, surgery, psychiatry, physical medicine and rehabilitation, neurology, oncology, dentistry, and geriatrics.


Duties

The Patient Aligned Care Team (PACT) RN Care Manager (RNCM) is a licensed professional RN who is assigned to a designated panel of patients within Primary Care. The PACT RNCM works in partnership with other team members, which includes the patient, to effectively and efficiently deliver and manage preventative, proactive, patient-driven care and chronic disease management and care needs. The RNCM demonstrates leadership in delivering efficient, comprehensive, and continuous patient-driven holistic care through active patient care, collaboration, communication, and coordination of resources.

The RNCM actively collaborates with the PACT team members (patient, provider, Medical Support Assistant (MSA), and LPN) and larger Team (family/caregiver, internal and community-based services) in supporting the patient centered, patient-driven holistic plan of care. The RN Care Manager uses the nursing process and evidence-based practice to provide proactive, preventative and patient-driven care. As a member of the patient-aligned care team (PACT), the RN Care Manager is responsible for collaborating with services internal and external to the VA to facilitate and coordinate care transition in order to effectively and safely meet the patients' needs. The RNCM provides patient and family health education with a focus on self-management, prevention, and wellness, based on the patient's goals. The RNCM serves as an advocate for patients and actively engages with his/her team and colleagues as she/he continues to enhance his/her own and the team's professional growth, development and practice. Duties include but not limited to:

  • Demonstrates advanced clinical knowledge in assessing, planning, implementing, documenting, and evaluating care for a panel of patients across the continuum of care, recognizing the age related cognitive, physical, emotional, and chronological maturation needs of the adult and geriatric patient.
  • Participates in chronic disease management for panel in collaboration with provider. Engages in Shared Medical Appointments (SMA), and/or RNCM visits.
  • Utilizes the Primary Care Almanac and PACT Metrics to address population health management issues and improve Team processes.
  • Triages and applies a collaborative team approach in identifying, analyzing, and resolving patient care problems.
  • Assists in determining appropriate scheduling based on patient's clinical need. Right person, right place, right time
  • Collaborates with ancillary team members and resources within the clinic to manage clinic access issues. This may include assisting other nursing staff with maintaining clinic flow.
  • Promotes patient, family and team interactions, and problem solving by actively participating in interdisciplinary meetings to facilitate coordination and the achievement of identified goals.
  • Retains current knowledge of multidisciplinary resources, programs, and services, referring patients for community resources as appropriate. Demonstrates ability to collaborate and coordinate with all levels of services and disciplines.
  • Collaborate with patients to assess and identify needs, issues, care goals, and resources for achieving desired outcomes post hospital recovery and health maintenance/wellness by effectively using Motivational Interviewing and TEACH techniques.
  • Supports patient self-management by providing an ongoing relationship with the PACT with current information regarding all options, choices, and resources. Provides patient centered care while respecting patient's personal values, cultural, and belief system.
  • Utilizes approved Protocols and Guidelines to facilitate autonomy in providing care. Works at the top of scope of practice.
  • Accurately documents coordination and care provided in CPRS.
  • Manages patient care alerts in CPRS in a timely, safe and effective manner.
  • Serves as a resource for patient and family rights, responsibilities, and decision-making information and processes.
  • Actively participates in reviewing and updating policies, procedures, and standards to promote evidence-based, patient-driven care.
  • Maintains professional knowledge and skills based on current evidence-based practice. Maintains expertise in chronic care/disease management and Health Promotion/Disease Prevention.
  • Maintains effective working relationships with professionals and support personnel within the medical center and the community.
  • Applies critical thinking and analytical skills to identify barriers for optimal patient care delivery and utilizes processes improvement strategies to correct or improve current state.
  • Utilizes creativity and innovation. Recommends and participates in interdisciplinary opportunities to improve patient care or clinical efficiency.
  • As needed, provides back-up coverage for other team members and other PACT RNCM within the clinic.
Work Schedule: Monday through Friday with shifts between the hours of 7:00 AM to 8:00 PM
Financial Disclosure Report: Not Required






graph of estimated pay ranges
$50,458

$98,174





Job Details



Application Open Date

12/28/2017



Application Close Date

1/8/2018




Organization

Veterans Affairs, Veterans Health Administration



Who May Apply

US Citizens and Current VA Healthcare System Employees



Status

Full-Time




























  • More About VAOpen More About VA SectionClose More About VA Section

    • Annual leave shall accrue for full-time Nurses, and Nurse Anesthetists at the rate of 8 hours for each full biweekly pay period.

      This job opportunity announcement may be used to fill additional vacancies.

      It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.

      This position is in the Excepted Service and does not confer competitive status.

      United States Citizenship Required; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.

      VA encourages persons with disabilities to apply. The health related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority.

      Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.

      If you are unable to apply online or need to fax a document you do not have in electronic form, view the following link for information regarding an Alternate Application.





  • QualificationsOpen Qualifications SectionClose Qualifications Section

    • To qualify for this position, applicants must meet all requirements within 30 days of the closing date of this announcement.
      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.
      • Graduate of a school of professional nursing approved by the appropriate State-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). 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.
      • 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: Bachelor's Degree in Nursing (BSN) AND Three (3) years RN 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 year's of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 year's 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 year's of nursing practice/experience; OR a Doctoral degree.
      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.




  • BenefitsOpen Benefits SectionClose Benefits Section





  • How To ApplyOpen How To Apply SectionClose How To Apply Section

    • All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 01/08/2018 to receive consideration.

      1. To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire.
      2. Click Submit My Answers to submit your application package.

      NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.

      To verify your application is complete, log into your USA JOBS account, https://my.usajobs.gov/Account/Login, select the Application Status link and then select the more information link for this position. The Details page will display the status of your application, the documentation received and processed, and any correspondence the agency has sent related to this application. Your uploaded documents may take several hours to clear the virus scan process. To return to an incomplete application, log into your USA JOBS account and click Update Application in the vacancy announcement. You must re-select your resume and/or other documents from your USA JOBS account or your application will be incomplete.




  • Additional DetailsOpen Additional Details SectionClose Additional Details Section

    • Series: 0610-Nurse


      Job Pay Type: Per Year


      Job Openings: 1


      Job Position: CASC-10107036-18-KMS




      The Patient Aligned Care Team (PACT) RN Care Manager (RNCM) is a licensed professional RN who is assigned to a designated panel of patients within Primary Care. The PACT RNCM works in partnership with other team members, which includes the patient, to effectively and efficiently deliver and manage preventative, proactive, patient-driven care and chronic disease management and care needs. The RNCM demonstrates leadership in delivering efficient, comprehensive, and continuous patient-driven holistic care through active patient care, collaboration, communication, and coordination of resources.

      The RNCM actively collaborates with the PACT team members (patient, provider, Medical Support Assistant (MSA), and LPN) and larger Team (family/caregiver, internal and community-based services) in supporting the patient centered, patient-driven holistic plan of care. The RN Care Manager uses the nursing process and evidence-based practice to provide proactive, preventative and patient-driven care. As a member of the patient-aligned care team (PACT), the RN Care Manager is responsible for collaborating with services internal and external to the VA to facilitate and coordinate care transition in order to effectively and safely meet the patients' needs. The RNCM provides patient and family health education with a focus on self-management, prevention, and wellness, based on the patient's goals. The RNCM serves as an advocate for patients and actively engages with his/her team and colleagues as she/he continues to enhance his/her own and the team's professional growth, development and practice. Duties include but not limited to:

      • Demonstrates advanced clinical knowledge in assessing, planning, implementing, documenting, and evaluating care for a panel of patients across the continuum of care, recognizing the age related cognitive, physical, emotional, and chronological maturation needs of the adult and geriatric patient.
      • Participates in chronic disease management for panel in collaboration with provider. Engages in Shared Medical Appointments (SMA), and/or RNCM visits.
      • Utilizes the Primary Care Almanac and PACT Metrics to address population health management issues and improve Team processes.
      • Triages and applies a collaborative team approach in identifying, analyzing, and resolving patient care problems.
      • Assists in determining appropriate scheduling based on patient's clinical need. Right person, right place, right time
      • Collaborates with ancillary team members and resources within the clinic to manage clinic access issues. This may include assisting other nursing staff with maintaining clinic flow.
      • Promotes patient, family and team interactions, and problem solving by actively participating in interdisciplinary meetings to facilitate coordination and the achievement of identified goals.
      • Retains current knowledge of multidisciplinary resources, programs, and services, referring patients for community resources as appropriate. Demonstrates ability to collaborate and coordinate with all levels of services and disciplines.
      • Collaborate with patients to assess and identify needs, issues, care goals, and resources for achieving desired outcomes post hospital recovery and health maintenance/wellness by effectively using Motivational Interviewing and TEACH techniques.
      • Supports patient self-management by providing an ongoing relationship with the PACT with current information regarding all options, choices, and resources. Provides patient centered care while respecting patient's personal values, cultural, and belief system.
      • Utilizes approved Protocols and Guidelines to facilitate autonomy in providing care. Works at the top of scope of practice.
      • Accurately documents coordination and care provided in CPRS.
      • Manages patient care alerts in CPRS in a timely, safe and effective manner.
      • Serves as a resource for patient and family rights, responsibilities, and decision-making information and processes.
      • Actively participates in reviewing and updating policies, procedures, and standards to promote evidence-based, patient-driven care.
      • Maintains professional knowledge and skills based on current evidence-based practice. Maintains expertise in chronic care/disease management and Health Promotion/Disease Prevention.
      • Maintains effective working relationships with professionals and support personnel within the medical center and the community.
      • Applies critical thinking and analytical skills to identify barriers for optimal patient care delivery and utilizes processes improvement strategies to correct or improve current state.
      • Utilizes creativity and innovation. Recommends and participates in interdisciplinary opportunities to improve patient care or clinical efficiency.
      • As needed, provides back-up coverage for other team members and other PACT RNCM within the clinic.
      Work Schedule: Monday through Friday with shifts between the hours of 7:00 AM to 8:00 PM
      Financial Disclosure Report: Not Required





Best Care / Best Careers

To care for him who shall have borne the battle and for his widow and his orphan." These words, spoken by Abraham Lincoln during his Second Inaugural Address, reflect the philosophy and principles that guide VA in everything we do, and are the focus of our endeavors to serve our Nation's veterans and their families.

 The Department of Veterans Affairs (VA) has one of the most diverse, challenging, and rewarding missions in the United States Government. We strive to meet the needs of the Nation's veterans and their families today and in the future.

VA manages one of the largest health care systems in the world and the nation's leading employer of registered nurses. Nurses in Veterans Health Administration (VHA) are engaged in a variety of roles and have multiple opportunities for career and professional development. The VHA provides veterans and their dependents with many other services such as benefits and education, and also provides burial benefits.

Our goal is to provide excellence in patient care, veterans' benefits and customer satisfaction. We can provide you with challenging, interesting, meaningful work to care for the veterans who have risked their lives to protect our freedom.

 As the Department of Veterans Affairs heads into the 21st century, we will strive to meet the needs of the Nation's veterans today and tomorrow. We are a more customer-focused organization, functioning as "One-VA" and delivering seamless service to our customers.

We benchmark our service with the best in business. We use innovative means and high technology to deliver "World-Class Customer Service". We foster partnerships with our customers and stakeholders, making them part of the decision-making process.

Department of Veterans Affairs is an Equal Opportunity Employer.

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