JOB REQUIREMENTS: Duties The Primary Care RN practices as a Care Managerand is a member of the Teamlet and provides patient-centered,evidence-based, patient driven care in all patient interactions acrossthe care continuum. The RN Care Manager is responsible for collaboratingwith services internal and external to the VA to facilitate caretransition in order to effectively meet the patients\' needs. The RNCare Manager conducts a comprehensive assessment of patients\' needs andprovides patient and family health education with a focus onself-management, prevention, resources, and wellness, based on thepatient\'s needs/goals. The RN Care Manager demonstrates leadership byserving as an advocate for patients, and a team leader with colleaguesas she/he continues to enhance his/her own and the team\'s professionalgrowth, development and practice. MAJOR DUTIES AND RESPONSIBILITIES:Demonstrates advanced clinical knowledge in assessing planning,implementing, documenting, and evaluating care for a designated group ofpatients across the continuum of care: Recognizing the age relatedcognitive, physical, emotional, and chronological maturation needs ofthe adult and geriatric patient. Manages a designated panel of patientsand utilizes VA developed protocols to enhance preventions as well asmanage chronic diseases including HTN, DM, COPD, CHF. Triages andapplies a collaborative team approach in identifying, analyzing, andresolving patient care problems via face-to-face visits, virtual videoconnect, secure messaging and telephone calls. Collaborates withpatients to assess and identify needs, issues, care goals, and resourcesin critical factors for achieving desired outcomes for discharge, posthospital recovery and health maintenance/wellness. Partners with Veteranto support self-management, prevention, and wellness, utilizing HealthCoaching and Motivational Interviewing to assist with behavior changeand guidance towards his or her goals. Conducts follow up calls tohospitalizations and Emergency Department visits, reviews records, andcoordinates follow up care. Demonstrates ability to collaborate with alllevels of services and disciplines. Collaborates with patient, familyand care providers in any and all settings where care is being providedto evaluate and update changes in the patient-driven life plan andpatient management. Reviews options with patients and families,including costs, alternatives, risks/benefits and services. Performsother duties as assigned. VA offers a comprehensive total rewards...For full info follow application link. The United States Government doesnot discriminate in employment on the basis of race, color, religion,sex (including pregnancy and gender identity), national origin,political affiliation, sexual orientation, marital status, disability,genetic information, age, membership in an employee organization,retaliation, parental status, military service, or other non-meritfactor. ***** APPLICATION INSTRUCTIONS: Apply Online:ipc.us/t/B4DF68F90928425B