The Registered Nurse (RN) Care Coordinators are assigned to the Neuro and Lung Cancer Screening departments in the Medicine Service. A total of three (3) positions are available; two (2) positions are Full-Time and one (1) position is Part-Time 20 hours per week. These positions are located within the Specialty Clinics of the Outpatient Medicine HCG at VALB HCS. The Nurse Care Coordinator and Nurse Case Manager will work in close collaboration with the team. The position will work under the direction of the nursing supervisor. The overall role is to perform day to day and long-term care coordination and case management between various clinical services for evaluation, follow-up and management of abnormal studies and care coordination of Veteran needs across the continuum of care. This position will work closely with interdisciplinary providers to assess and problem solve patient care issues and educate team as issues are identified. The key aspect to the role of the nurse case manager will be discharge planning assessment and implementation of home health services, supplies, and activities required to successfully transition the patient to the appropriate non-acute care setting, home or skilled facilities. Also responsible and accountable for all elements of the nursing process when providing and/or supervising direct patient care. Assumes responsibility for the coordination of care focused on patient transition through the continuum of care, patient and family education, patient self-management after discharge, and supporting factors that impact customer satisfaction. Considers all characteristics of the individual, including age and life stages, state of health, race and culture, values, and previous experiences. Influences care outcomes by collaborating with members of the interdisciplinary team. Core elements of performance include knowledge and active participation in unit/program level quality improvement processes and initiatives as well as customer service programs. Care Coordinators are able to recognize the progression of diseases that they are working with and can anticipate the needs of these high risk Veterans. Other duties will include but not limited to: Chart reviews to ensure that Veterans are appropriate for this level of care. Telephone triage. Ensuring appointments are scheduled timely. They will be available to communicate with Veterans and their families re: questions, concerns including scheduling, transportation, lodging, referrals, and plan of care. They will facilitate communication between Veterans and various services / subspecialties. Accurately document all care and recommendations, communicating with providers as necessary to assure continuity of patient care. Works independently utilizing critical thinking skills for complex issues and able to act quickly to ensure all safety measures have been addressed and follow-up has been achieved. Assesses, plans, implements and evaluates care based on age-specific components. Administers medications and procedures per established policies and guidelines. Responsible in ensuring that diagnostic tests are completed timely. Work Schedule: 7:30AM to 4:00PM for Full-Time and 7:30AM to 12:00PM for Part-Time. Work schedule is subject to change based on the needs of the organization. Financial Disclosure Report: Not required
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.