Job Listing
Registered Nurse - Patient Aligned Care Team Care Manager
Veterans Health Administration · Posted 2 days ago
About the Role
Registered Nurse (RN) Patient Aligned Care Team Care Manager coordinates Veteran-centered care with Veterans, families, and the interdisciplinary team; supports care planning, discharge follow-up, and continuity of care; documents accurately in the electronic health record; advocates for patients; and participates in performance improvement, education, safety, and compliance activities.
What You'll Do
- →Major duties include, but are not limited to: Coordinate Veteran-centered care with Veterans, family members, and the interdisciplinary team.
- →Ensure accurate documentation and follow care coordination guidelines in the electronic health record.
- →Promote positive clinical, financial, and psychosocial outcomes for assigned Veterans with chronic and acute diagnoses.
- →Assist with post-hospital planning by identifying community resources and evaluating nursing care needs.
- →Integrate living conditions, family dynamics, and cultural background into the plan of care.
- →Complete post-discharge follow-up contacts to support understanding of medications, instructions, appointments, and appropriate level of care.
- →Advocate in the care management process by supporting decisions, clarifying options, and problem solving with the interdisciplinary team.
- →Collaborate across the health care system and Community-Based Outpatient Clinics to ensure continuity of care.
- →Monitor, analyze, and evaluate care outcomes to identify barriers and improve patient care delivery.
- →Provide nursing care for Veterans with a variety of health care needs and diagnoses while communicating effectively with internal and external customers.
- →Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized The VA Midwest Health Care Network advocates for a Whole Health System of care in each of the Medical Centers.
- →This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest.
- →As an employee operating in a Whole Health System of care, you will operate in a model with three core elements, seeking to create a personalized health plan for each Veteran.
- →This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community.
Requirements
- ✓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 examination.
- ✓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.
Personality Fit
Job ID: bf4b6b82-e9b1-44a1-b093-1571dece56b2
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