Home-Based Primary Care, RN, Care Manager

We are seeking a dynamic and experienced leader to join our HBPC team as a RN Case Manager. The HBPC RNCM is responsible for ongoing assessment, care coordination, health promotion, patient education, and disease management for assigned Veterans. This role emphasizes preventive care, chronic disease management, and maintaining the Veteran's highest level of independence and quality of life in the home environment.Duties listed but not limited to:Assess, evaluates, plans, implements, and coordinates care, and confers with other Home-Based Primary Care providers to evaluate and initiate changes to ensure quality care.Helps Veterans to self-manage chronic diseases such as diabetes, hypertension, congestive heart failure, chemical dependency, cancer, dementia, and any other conditions that may warrant additional attention.Triages and applies collaborative team approach in identifying, analyzing, and resolving Veteran's care problems, and developing care goals for resolving or managing these issues.Focuses on wellness and patient education and uses motivational interviewing techniques to help the Veteran meet his/her goals.Collaborates with services, internal and external, to facilitate care.Maintains a current knowledge of interdisciplinary resources, programs and services to include community resources as appropriate.Establish methods to monitor patients' progress, including performing injections, venipunctures and catheter care and management and maintain appropriate documentation within designated timeframes.Conduct comprehensive home assessments and develop individualized nursing care plans.Manage chronic conditions, provide wound care, medication management, and health education.Coordinate multidisciplinary care to support Veterans' physical, emotional, and social well-being.Document care activities and outcomes in the electronic health record (EHR).Participate in quality improvement initiatives.Promote safety, independence, and prevention of hospitalizations.Other duties as assignedVA offers a comprehensive total rewards package: VA Nurse Total RewardsPay: Competitive salary, regular salary increases, potential for performance awardsPaid 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 VAInsurance: 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 territoryWork Schedule: Mon-Fri 0800-1630Telework: Not AvailableVirtual: This is not a virtual position.Relocation/Recruitment Incentives: Not AuthorizedPermanent Change of Station (PCS): Not Authorized