Registered Nurse-Home Telehealth Care Coordinator

The Remote Patient Monitoring (RPM) Home Telehealth (HT) Registered Nurse (RN) Care Coordinator executes position responsibilities that demonstrate beginning leadership skills and participates in specific HT experiences. They demonstrate creative approaches to the management of aspects of complex patient care. The Home Telehealth Care Coordinator Registered Nurse works to improve clinical outcomes and access to care while reducing complications, hospitalizations, and clinic or emergency room visits for Veterans in post-acute care settings and high-risk patients with chronic and mental health disease. • Provides initial and ongoing comprehensive assessment to include a review of systems which establishes a comprehensive plan of care. • Identifies, analyzes, and prioritizes problems and interventions and sets appropriate SMART goals(Specific, Measurable, Achievable, Realistic, Time-based). • Triages and assesses all data received from Home Telehealth patients such as vital signs, reported symptoms and question responses. • Identifies and intervenes for potential exacerbations of complications to facilitate timely care in Patient Aligned Care Team (PACT) clinic, Emergency Department (ED)/Urgent Care (UC), and or/care in the community. • The HT RN provides communication and data exchange with community-based providers when there is co-managed care. • Provides interdisciplinary consultation and interventions such as with Home Based Primary Care (HBPC) and other non-institutional care programs and venues, Mental Health (MH), Social Work (SW), Pharmacy, Nutrition, etc. • The HT RN identifies patients' knowledge, health factors, skills, and behaviors that support self-management and identify gaps therein. • Provides health care coaching, patient education, and motivational counseling. • Communicates and facilitates with the interdisciplinary team regarding progress to goals; patterns or trends of data, symptoms or findings; concerning findings; need for provider assessment and/or interventions. • Establishes a therapeutic relationship, allowing the patient to attain, maintain or regain optimal function through assessment and treatment. VA offers a comprehensive total rewards package: VA Nurse Total Rewards Pay: Competitive salary, regular salary increases, potential for performance awards Paid Time Off: 50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Licensure: 1 full and unrestricted license from any US State or territory Work Schedule: Monday-Friday 07:30am-04: 00pm and as patient care dictates. Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized