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Registered Nurse - Care Coordinator

Duties include but not limited to: Remote Patient Monitoring (RPM) Home Telehealth (HT) Registered Nurse (RN) Care Coordinator executes position responsibilities that demonstrates leadership, experience, and creative approaches to the management of complex patient care. Care will be provided in the least restrictive, most cost-effective manner. HT is a program that applies care and case management principles to coordinate care using health informatics, disease management and HT technologies to facilitate access to care and to improve the health of Veterans with the specific intent of providing the right care, in the right place, at the right time. The HT RN works to improve clinical outcomes and access to care while reducing complications, hospitalizations, and clinic or emergency room visits for Veterans in post-acute care settings and high-risk patients with chronic and mental health disease. Provides initial and ongoing comprehensive assessment to include a review of systems which establishes a comprehensive plan of care. Triages and assesses all data received from HT patients such as vital signs, reported symptoms and question responses. Identifies and intervenes for potential exacerbations of complications to facilitate timely care in Patient Aligned Care Team (PACT) clinic, Emergency Department (ED)/Urgent Care (UC), and or/care in the community. The HT RN provides communication and data exchange with community-based providers when there is co-managed care. Provides interdisciplinary consultation and interventions such as with Home Based Primary Care (HBPC) and other non-institutional care programs and venues, Mental Health (MH), Social Work (SW), Pharmacy, Nutrition, etc. The HT RN identifies patients' knowledge, health factors, skills, and behaviors that support self-management and identify gaps therein. Provides health care coaching, patient education, and motivational counseling. Communicates and facilitates with the interdisciplinary team regarding progress to goals; patterns or trends of data, symptoms or findings; concerning findings; need for provider assessment and/or interventions. Provides peers with informal constructive feedback for improvement. Fosters a safe and supportive environment conducive to the professional development of healthcare professionals. Contributes professional nursing perspective in discussions with the interdisciplinary team. Partners with others to effect change and produce optimal outcomes. Supports colleagues through knowledge sharing to provide safe, quality nursing care. Shares educational findings, experiences, and ideas with peers. Questions clinical practices for the purpose of providing evidence-based care. Participates in activities and strategies to sustain evidence-based-practice.

VA offers a comprehensive total rewards package: VA Nurse Total Rewards Work Schedule: 07:00 -1530 Telework: Ad-hoc at Supervisors discretion Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not authorized Permanent Change of Station (PCS) : Not authorized

The Department of Veterans Affairs is implementing a streamlined 30-Day Hiring Model designed to accelerate hiring while maintaining the highest standards of merit-based selection. This improved process reduces traditional hiring timelines by integrating early coordination, faster assessments, and efficient pre-employment actions. Applicants can expect a more transparent, predictable, and efficient hiring journey from announcement to entry on duty.

• Expedited Candidate Review Once the announcement closes, Human Resources will quickly review applications, issue certificates of eligible candidates the day after the announcement closes and refer applicants for hiring manager consideration.
• Quick Interviews & References HR may arrange interviews and will request references within 3-5 days after being referred to the hiring manager.
• Streamlined Pre-Employment Requirements: Following a tentative offer, applicants should be prepared to complete required steps, such as fingerprinting and background check, credentialing, and medical examination within 3 days of the offer.
• Clear and Timely Communication: Applicants will receive clear communication at key milestones, including referral, tentative offer, and onboarding instructions.

After meeting pre-employment requirements, candidates will receive a final job offer and start date. Onboarding tasks may continue after starting, with HR ensuring timely completion for a smooth transition into VA service. If selected, applicants should be prepared to come onboard within 30 days of the announcement closing.