Registered Nurse - Home Telehealth - Case Manager/Care Coordinator

Veterans Health Administration • Baltimore, MD

1d • Onsite

About The Position

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 education, self-management, and customer satisfaction throughout the continuum of care. Influences care outcomes by collaborating with members of the interdisciplinary team. The Registered Nurse (RN) Case Management (CM) is responsible for providing competent, evidence-based care to assigned patients. Provides patient management, care coordination, and discharge/disposition planning for inpatient and outpatient settings. The CM RN assists Veterans, family members, and caregivers with receiving the most appropriate options and services to meet their complex health care needs. This includes, but is not limited to, acute, chronic, multiple, complex, catastrophic, or life-threatening illnesses; combat stress, residuals of traumatic brain injury; community adjustment; addictions and other health problems. Coordinates care with multiple providers across all levels and sites of care. The RN CM addresses psychosocial, as well as nursing and medical needs of patients and their families/caregivers, through participation in interdisciplinary patient care management practice. The CM RN also evaluates care and outcomes to ensure timely and appropriate provision of services. Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others. Evaluates practice in an ongoing process, based on best evidence. 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 CM 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 an evidence-based-practice culture. Remote Patient Monitoring-Home Telehealth (RPM-HT) is focused on providing specific in-home telehealth technology to a selected group of patients with specific chronic illnesses who are high utilizers of healthcare services. The role of the RPM-HT nurse requires the ability to use various software applications and telehealth monitoring devices, to interpret specific clinical data as it relates to disease management. In addition, the RPM-HT nurse must relate well with patients, family members, and members of the care team. The incumbent also should have a comprehensive knowledge of hospital systems, familiarity with personnel in multiple departments, and the ability to advocate for the best interest of the patient with all clinical staff. He/she is responsible for the provision of high-quality, customer-focused, and cost-effective patient care in the community. The RPM-HT nurse is responsible for educating the patient/family on the technology to be used, as well as, assessing, planning, and coordinating care based on the needs of the patient. The incumbent will provide patient education, monitoring of patient status using home telehealth technology, transfer of patient data into CPRS and other software packages as designated, and timely communication to the provider when critical information is received.

Requirements

• U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment.
• Applicants who refuse to be tested will be denied employment with VA.
• Selective Service Registration is required for males born after 12/31/1959.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process.
• Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents).
• Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Must pass pre-employment physical evaluation.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• You may be required to serve a probationary period.
• Complete all application requirements detailed in the "Required Documents" section of this announcement.
• 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 5019, Part II-Physical Requirements).
• 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.)
• Registered Nurse (RN) with at least 2 years of experience in Care Coordination and/or Case Management
• Five (5) or more years of successful RN experience in Medical-Surgical Nursing and/or Ambulatory/Primary Care/Home Telehealth experience

Nice To Haves

• MSN preferred

Responsibilities

• Provides patient management, care coordination, and discharge/disposition planning for inpatient and outpatient settings.
• Assists Veterans, family members, and caregivers with receiving the most appropriate options and services to meet their complex health care needs.
• Coordinates care with multiple providers across all levels and sites of care.
• Addresses psychosocial, as well as nursing and medical needs of patients and their families/caregivers, through participation in interdisciplinary patient care management practice.
• Evaluates care and outcomes to ensure timely and appropriate provision of services.
• Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others.
• Evaluates practice in an ongoing process, based on best evidence.
• 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 CM 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 an evidence-based-practice culture.
• Uses various software applications and telehealth monitoring devices.
• Interprets specific clinical data as it relates to disease management.
• Relates well with patients, family members, and members of the care team.
• Advocates for the best interest of the patient with all clinical staff.
• Educates the patient/family on the technology to be used.
• Assesses, plans, and coordinates care based on the needs of the patient.
• Provides patient education.
• Monitors patient status using home telehealth technology.
• Transfers patient data into CPRS and other software packages as designated.
• Provides timely communication to the provider when critical information is received.

Benefits

• Competitive salary
• Regular salary increases
• Potential for performance awards
• 50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year)
• Traditional federal pension (5 years vesting)
• Federal 401K with up to 5% in contributions by VA
• Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)
• 1 full and unrestricted license from any US State or territory

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree