Registered Nurse-Remote Patient Monitoring Home Telehealth Case Manager

Veterans Health Administration • Orlando, FL

3d • Hybrid

About The Position

The Remote Patient Monitoring Home Telehealth Case Manager delivers knowledge-based nursing care to assigned clients and develops technical skills. The position assesses, plans, implements, and evaluates care using age-specific components, and coordinates care focused on patient education, self-management, and customer satisfaction across the continuum of care.

Home Telehealth applies care and case-management principles, health informatics, disease management, and telehealth technologies to coordinate access to care and improve the health of Veterans. The program aims to provide the right care in the right place at the right time, improve clinical outcomes and access, and reduce complications, hospitalizations, and clinic or emergency-room visits among Veterans in post-acute care settings and high-risk patients with chronic or mental health conditions.

The case manager provides comprehensive initial and ongoing assessments, including review of systems, and develops plans of care. They triage and assess data received from telehealth patients, including vital signs, reported symptoms, and questionnaire responses, and intervene when potential complications or exacerbations are identified. Care may be coordinated with Patient Aligned Care Team clinics, emergency or urgent care, community providers, and interdisciplinary programs and services. The position also supports patient self-management through coaching, education, and motivational counseling.

The position is scheduled Monday through Friday, 0730–1600. Ad-hoc telework is available; this is not a virtual position. Relocation and recruitment incentives, and permanent change of station, are not authorized.

Requirements

• Proficiency in basic written and spoken English.
• Graduation from an appropriately accredited school of professional nursing, or qualifying nursing education as specified for eligible bridge-program candidates and foreign-school graduates.
• Current, full, active, and unrestricted registered professional nurse licensure in a U.S. State, Territory, or Commonwealth, or the District of Columbia; a temporary Graduate Nurse Technician appointment may be available to eligible candidates pursuing licensure.
• Meet the education, experience, and dimension criteria for the assigned Nurse grade and level.
• U.S. citizenship, unless appointment of a non-citizen is permitted under VA policy when qualified citizens cannot be recruited.
• Pass a pre-employment physical evaluation or examination.
• Complete required pre-employment screening, background/security investigation, onboarding, and application documentation.
• Participate in the seasonal influenza vaccination program.
• Males born after December 31, 1959, must meet Selective Service registration requirements.
• A probationary period may be required.

Nice To Haves

• Primary care care-management, care-coordination, or case-management experience is strongly preferred.
• A BSN or MSN is highly preferred.
• National certification in care management or care coordination is preferred.
• Demonstrated ability to make critical decisions in stressful environments.
• Demonstrated dependability and flexibility in work assignments and hours.

Responsibilities

• Provide nursing care and counseling to promote and maintain health and prevent illness and injury, using systematic data gathering, assessment, nursing judgment, and evaluation.
• Provide health teaching and counseling, supportive or restorative care, and execute medical regimens in accordance with established policies, procedures, and guidelines.
• Collaborate with interdisciplinary team members to influence care outcomes and coordinate care.
• Demonstrate beginning leadership skills, participate in Home Telehealth experiences, and apply creative approaches to complex patient care management.
• Provide care in the least restrictive and most cost-effective manner.
• Conduct initial and ongoing comprehensive assessments, including a review of systems, and establish a comprehensive plan of care.
• Triage and assess telehealth patient data, including vital signs, reported symptoms, and responses to questions.
• Identify and intervene in potential exacerbations or complications to facilitate timely care in PACT clinics, emergency or urgent care, or community settings.
• Exchange information and coordinate with community-based providers when care is co-managed.
• Provide interdisciplinary consultation and interventions with Home Based Primary Care and other non-institutional care programs, Mental Health, Social Work, Pharmacy, Nutrition, and related services.
• 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 and coordinate with the interdisciplinary team regarding progress toward goals, data or symptom patterns and trends, concerning findings, and the need for provider assessment or intervention.
• Apply principles, theory, and critical-thinking skills to nursing practice.

Benefits

• Competitive salary, 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 and federal 401(k) with up to 5% in VA contributions.
• Federal health, vision, dental, term life, and long-term care insurance; many federal insurance programs can be carried into retirement.

What This Job Offers

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