Registered Nurse (PACT Care Manager/ Primary Care)
Veterans Affairs, Veterans Health Administration
Location: Fairview, Oregon
Internal Number: 630721100
The Registered Nurse (RN) assigned to the VAPORHCS Patient Aligned Care Team (PACT) Primary Care Clinic functions as the PACT Nurse Care Manager (NCM). The PACT NCM is a member of the PACT Teamlet (Primary Care Provider, Nurse Care Manager, Licensed Practical Nurse, Health Technician, and Clerical Associate) and supports the work of the expanded team (Pharmacist, Social Worker, Home Telehealth RN, Psychologist, and Dietician). The NCM demonstrates advanced clinical knowledge in assessing, planning, implementing, documenting, and evaluating care for an assigned panel of patients at VAPORHCS. The duties include but are not limited to: Recognizes the age-related cognitive, physical, emotional, and chronological maturation needs of the adult and geriatric patient focusing on chronic disease management. Identifies and provides case management for high-risk cohort of patients utilizing chronic disease management data mining tools. Utilizes registries to manage disease processes such as Diabetic, Mammography, Cardiovascular, and Opioid Registries to access data base for pain management. Performs timely Post-Discharge/ ED/ Urgent Care and Walk-ins' using appropriate documentation templates/notes, codes, education. Assesses and enrolls eligible patients into nontraditional modalities of care such as Home telehealth and Telemedicine. Provides patient and family education with a focus on self-management, prevention, and wellness, based on 'what matters most' to the patient. Reviews, tracks, and devises strategies to improve Healthcare Effective Data Information Sets (HEDIS) metrics, clinical reminders, panel access, timely encounter closures, and other performance metrics. Facilitates continuity of care by partnering with multidisciplinary services, internal and external to the Department of Veterans Affairs. Collaborates with PACT and Expanded PACT to participate/provide shared medical appointments/ group clinics for patients with specific chronic disease diagnoses. Provides VA Video Connect (VVC), Clinical Video Technology (CVT), or Telemedicine. The NCM is responsible for maintaining knowledge of and skill in applying an intensive body of rules, procedures, and operations in telehealth related technologies and a variety of computer hardware/ software used in technology, data entry, retrieval, record maintenance, document, and report generation. The NCM may be required to perform specimen collection of (urine, sputum, blood, or stool) ensuring to utilize proper labeling, packaging, and transport instructions from the Primary Care Community Based Clinics or assigned areas to the main facility laboratory. Demonstrates knowledge, skill, and competency in venipuncture and specimen collection. Work Schedule: Monday thru Friday, varying tours from 7:00 am to 5:30 pm. Compressed/Flexible: Not available Telework: Not available Virtual: This is not a virtual position Relocation/Recruitment Incentives: Not Authorized EDRP: Not Authorized Permanent Change of Station (PCS): Not Authorized 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.