The VA Maryland Health Care System (VAMHCS) is a Level I tertiary multi campus teaching facility affiliated with the University of Maryland, School of Medicine and over 100 educational institutions. The VAMHCS consists of the acute care Baltimore facility; the multi building Perry Point campus with acute medicine, mental health and long term care; the Loch Raven campus with long term care; and six urban and rural outpatient clinics. The Patient Aligned Care Team Nurse Coordinator is a self-directed professional registered nurse (RN) who assumes leadership role in direct and indirect care management of a group of patients through the coordination of care with physicians, nurse practitioners, medical residents/students, other health care professionals and hospital systems. The incumbent is accountable for adhering to established policies, standards of care and standards of practice set forth by the Joint Commission. The RN will assume care coordinating responsibility for the patients assigned to them in the management of chronic and acutely ill patients. The incumbent will work with the patient care team to guide, teach and implement patient care plans. The RN works with the team to ensure that the needs of the patient are met in a timely manner and in a customer focused environment. In addition to face- to- face communication, the RN will communicate telephonically and return phones calls, and take messages in collaboration with the team members to ensure that all patients' management/care coordination issues are addressed in a timely manner. The incumbent will assist patients in preparing for upcoming appointments and ensure patients are informed. The RN will be responsible for providing intensive management and coordination of care for patients with acute and chronic disease states in Primary Care environment. The RN will provide the Nursing Leadership and guidance for other team members in providing direct and indirect care for an assigned group of patients. The RN along with the provider will be responsible for ensuring that assigned patients are meeting the prescribed clinical goals to include Ambulatory Care sensitive indicators, HEDIS, and applicable ORHS measures. The RN will be responsible for using computer applications to monitor and report clinical data. Work Schedule: 8 hour shifts between the hours of 7:30am-5:30pm, Monday-Friday. Occasional Saturdays 8:00am-12:00pm. No holidays. Functional Statement# Nurse 000000 Telework Eligibility: No
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.