JOB REQUIREMENTS: Duties The Intermittent (NON-Benefit position) inPrimary Care (RN) practices as a Care Manager and is a member of theTeamlet and provides patient-centered, evidence-based, patient drivencare in all patient interactions across the care continuum. The RN CareManager is responsible for collaborating with services internal andexternal to the VA to facilitate care transition in order to effectivelymeet the patients\' needs. The RN Care Manager conducts a comprehensiveassessment of patients\' needs and provides patient and family healtheducation with a focus on self-management, prevention, resources, andwellness, based on the patient\'s needs/goals. The RN Care Managerdemonstrates leadership by serving as an advocate for patients, and ateam leader with colleagues as she/he continues to enhance his/her ownand the team\'s professional growth, development and practice. MAJORDUTIES AND RESPONSIBILITIES: Demonstrates advanced clinical knowledge inassessing planning, implementing, documenting, and evaluating care for adesignated group of patients across the continuum of care: Recognizingthe age related cognitive, physical, emotional, and chronologicalmaturation needs of the adult and geriatric patient. Manages adesignated panel of patients and utilizes VA developed protocols toenhance preventions as well as manage chronic diseases including HTN,DM, COPD, CHF. Triages and applies a collaborative team approach inidentifying, analyzing, and resolving patient care problems viaface-to-face visits, virtual video connect, secure messaging andtelephone calls. Collaborates with patients to assess and identifyneeds, issues, care goals, and resources in critical factors forachieving desired outcomes for discharge, post hospital recovery andhealth maintenance/wellness. Partners with Veteran to supportself-management, prevention, and wellness, utilizing Health Coaching andMotivational Interviewing to assist with behavior change and guidancetowards his or her goals. Conducts follow up calls to hospitalizationsand Emergency Department visits, reviews records, and coordinates followup care. Demonstrates ability to collaborate with all levels of servicesand disciplines. Collaborates with patient, family and care providers inany and all settings where care is being provided to evaluate and updatechanges in the patient-driven life plan and patient management. Reviewsoptions with patients and families, including costs, alternatives,risks/benefits and services. Performs other duties as assigned. VAoffers... For full info follow application link. The United StatesGovernment does not discriminate in employment on the basis of race,color, religion, sex (including pregnancy and gender identity), nationalorigin, political affiliation, sexual orientation, marital status,disability, genetic information, age, membership in an employeeorganization, retaliation, parental status, military service, or othernon-merit factor. ***** APPLICATION INSTRUCTIONS: Apply Online:ipc.us/t/17B6CB2F024D4FD5