Registered Nurse - Home Telehealth Care Coordinator

Home Telehealth Care Coordinator (HTCC) Registered Nurse (RN) demonstrates leadership, experience, and creative approaches to management of complex patient care. The HTCC is responsible for coordination of health care for a defined patient population, identified as high resource users or at high risk for decline. Patients receive goal-oriented, coordinated care addressing holistic needs with the aim of preventing disease complications, maximizing functional ability, and quality of life.

This is an intermittent position within Connected Care and is located at the Martinsburg VA Health Care System. The functions and responsibilities of the HTCC include but is not limited to: Adhering to established policies, standards of care and standards of practice is consistent with the plan of other health care providers Coordinating and facilitating the provision of clinical and psychosocial services in a setting best suited to the services and to the healthcare needs of assigned patients. Implementing measures to improve access to care and the provision of timely health care interventions. Working collaboratively with the patient, family/significant other, and members of the interdisciplinary team to implement a plan of care across the continuum to meet each patients individual needs and maintain or improve quality of life. Promoting strategies that contribute to the effective and efficient use of Medical Center and VISN resources. Providing care for his/her panel of patients through tele-health technology engaging the patient in self-responsibility for healthcare agency (can you? will you?). Being accountable for patient care follow-up to meet established clinical guidelines/performance measures. Reviewing consults of patients to assign telehealth technology, coordinating follow-up care for patients across the continuum, and providing interventions to reduce hospitalizations and ER visits in collaboration with the Primary Care Team. Enhancing patient satisfaction and patient advocacy. Providing consultation to other health care providers, disciplines, and departments; e.g. Home Telehealth for optimizing blood glucose in diabetic patients. Teaching other members of the health care team regarding clinical, fiscal and system processes related to nursing case management with home telehealth technology. Providing data about indicators related to clinical and fiscal outcomes. Collecting, analyzing, and sharing of data and information in order to influence performance improvement goals. Providing leadership in the application of the nursing process to client care, organizational processes in order to improve outcomes at the program level. Serving as a liaison to the patient, his/her family, and members of the multidisciplinary team and hospital systems, to facilitate the management of patient-centered care" right care, right place, and right time. Adhering to appropriate interpersonal skills, working closely with all members of the interdisciplinary team. Assuming the role of educating staff to meet changing program or service needs and consulting regarding issues such as care planning, policy interpretation and others. Responsible for the documented outcomes at the program or service level. Program of service level outcomes must be broad and complex and can be demonstrated at any organizational level. 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: Intermittent. Telework: Not Available. Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized. Permanent Change of Station (PCS): Not Authorized.

U.S. 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 evaluation. 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.