Registered Nurse - Home Telehealth Case Manager/Care Coordinator - EDRP Authorized

Veterans Health Administration • Big Spring, TX

3d • Hybrid

About The Position

The Registered Nurse is responsible and accountable for all elements of the nursing process when providing or supervising direct patient care. The role coordinates care across the continuum, with a focus on patient education, self-management, and customer satisfaction. It applies nursing leadership and case-management principles, health informatics, disease management, and home telehealth technologies to help Veterans receive appropriate care at the right time and place and to improve clinical outcomes and access while reducing complications, hospitalizations, and clinic or emergency visits.

The nurse provides comprehensive initial and ongoing assessments and care plans, reviews and triages home-telehealth data, and responds to potential complications or exacerbations through timely coordination with PACT clinics, emergency or urgent care, community providers, and interdisciplinary services. The position supports Veterans in post-acute care and high-risk populations, including people with chronic or mental health conditions. It also promotes self-management through education, coaching, and motivational counseling; communicates patient progress and concerns to the care team; and contributes to evidence-based nursing practice, peer learning, and professional development.

The position is scheduled Monday through Friday, either 8:00 a.m.–4:30 p.m. or 7:30 a.m.–4:00 p.m. Ad hoc telework is eligible; this is not a virtual position. A pre-placement physical examination will assess the incumbent’s ability to safely operate a government-owned vehicle. EDRP is authorized, subject to program eligibility restrictions.

Requirements

• Proficiency in basic written and spoken English.
• Graduation from a professional nursing program accredited by ACEN or CCNE, or qualifying equivalent education as specified for foreign nursing graduates or eligible nursing bridge-program candidates.
• Current, full, active, and unrestricted professional nurse registration in a U.S. State, Territory, Commonwealth, or the District of Columbia; an exception may apply to eligible Graduate Nurse Technicians appointed temporarily while pursuing licensure.
• Meet the education, experience, and practice-dimension criteria for the assigned VA Nurse grade and level. Applicable pathways range from an ADN or nursing diploma for Nurse I, Level I to specified combinations of nursing degrees and specialized experience for Nurse II and Nurse III.
• Submit transcripts when relying on education to meet qualification requirements; foreign education requires a foreign-equivalency certificate and transcript for credit.
• Meet U.S. citizenship requirements, except that non-citizens may be appointed only when qualified citizens cannot be recruited under VA policy.
• Undergo required pre-employment drug screening, background/security investigation, onboarding, and pre-employment physical examination; comply with the seasonal influenza vaccination program and any applicable probationary period.
• Be able to safely operate a government-owned vehicle, as assessed by a pre-placement examination.
• Complete all application requirements detailed in the announcement’s Required Documents section.

Nice To Haves

• Three to four years of professional nursing experience in case management, care coordination, disease management, or a related clinical program, preferably serving Veterans or other high-risk populations.
• Experience with remote patient monitoring, home telehealth, telehealth nursing, or telephone- or video-based clinical care, including assessment and follow-up in patients’ homes or other nonclinical settings.
• Experience monitoring, trending, and responding to vital signs, biometric data, symptoms, and disease-management alerts under established clinical protocols.
• Experience caring for patients with complex chronic conditions, post-acute care needs, or risk of hospitalization or institutional long-term care, including developing and implementing individualized care plans.
• Demonstrated ability to provide patient education, health coaching, self-management support, and motivational communication to promote adherence and improve outcomes while reducing avoidable emergency visits and hospitalizations.
• Experience collaborating with interdisciplinary teams, primary care teams, specialty services, patients, families, and caregivers to coordinate services, communicate changes in clinical status, and support timely interventions.

Responsibilities

• Provide and/or supervise direct patient care and carry out all elements of the nursing process.
• Coordinate care focused on patient education, self-management, and customer satisfaction across the continuum of care.
• Apply leadership and case-management principles, health informatics, disease management, and home telehealth technologies to facilitate access to appropriate care.
• Work to improve clinical outcomes and access to care while reducing complications, hospitalizations, and clinic or emergency room visits for Veterans in post-acute care and high-risk populations.
• Conduct initial and ongoing comprehensive assessments, including reviews of systems, and establish comprehensive plans of care.
• Triage and assess home-telehealth patient data, including vital signs, reported symptoms, and responses to questions.
• Identify and intervene in potential exacerbations or complications, coordinating timely care through PACT clinics, emergency departments, urgent care, or community care as appropriate.
• Communicate and exchange data with community-based providers when care is co-managed.
• Consult and coordinate interventions with interdisciplinary services and programs, including HBPC, mental health, social work, pharmacy, and nutrition.
• Identify patients’ knowledge, health factors, skills, and behaviors that support self-management, and identify gaps.
• Provide health care coaching, patient education, and motivational counseling.
• Communicate patient progress toward goals, data or symptom trends, concerning findings, and needs for provider assessment or intervention to the interdisciplinary team.
• Provide peers with informal constructive feedback and support professional development and knowledge sharing.
• Contribute a professional nursing perspective to interdisciplinary discussions and partner with others to achieve optimal outcomes.
• Question clinical practices and participate in activities that sustain evidence-based care.
• Share educational findings, experiences, and ideas with peers to support safe, quality nursing care.

Benefits

• Competitive salary with regular salary increases and potential performance awards.
• 50 days of paid time off per year: 26 days of annual leave, 13 days of sick leave, and 11 paid Federal holidays.
• Traditional federal pension, with five-year vesting.
• Federal 401(k), with VA contributions of up to 5%.
• Federal health, vision, dental, term life, and long-term care insurance; many federal insurance programs can be carried into retirement.
• One full and unrestricted license from any U.S. State or territory is accepted for licensure purposes.

What This Job Offers

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