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    These positions are located in the Connected Care Service of the Washington DC VA Medical Center. As a Registered Nurse - Home Telehealth Care Coordinator, you will be responsible and accountable for independently case managing a group of patients enrolled in the Home Telehealth (HT) Program. You will be responsible for a panel of Veterans with specific diseases that involve interfacing with health team members in clinics and in-patient units.

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    • Demonstrates leadership and mastery of practice in delivering efficient, comprehensive, and continuous patient-driven holistic care through active collaboration, communication and coordination of resources.
    • Utilizes core elements of performance including knowledge and active participation in unit/service level quality improvement processes, such as the customer service program.
    • Uses the nursing process to ensure patient care is coordinated in collaboration with members of the health team.
    • The CCHT RN seeks to enroll veterans that meet the HT inclusion criteria; completes a detailed clinical assessment, registers patients on web-based Telehealth servers; orients veterans to the Telehealth equipment.
    • Demonstrates the ability to identify and issue, analyze it, develop and implement interventions.
    • Assessing, planning, implementing, monitoring, evaluating, and advocating, reconciling medications, providing health education, making referrals for VA/Community services.
    • Provides care in a non-judgmental, non-discriminatiory manner that is sensitive to the adult or elderly patient and family's diversity, preserving they autonomy, dignity, and rights.
    • Basic Life Support (BLS) required for RNs in direct patient care positions.
    • Uses motivational interviewing in setting SMART goals with veteran and then completes treatment plan updates every 180 days.
    • Interfaces with all in-patient and Ambulatory case manager nurses to coordinate home care and Telehealth monitoring.
    • Educates health care team about Telehealth services and the essential elements of the care coordination processes.
    • Participates in weekly Home Telehealth staff meetings, interfaces with PACT teams and meets with other specialty healthcare teams frequently to coordinate patients care.
    • Monitors daily measurement data and responses to disease management questions to pick up subtle changes in condition to provide just-in-time care.

    Travel Required

    Occasional travel - You may be expected to travel for this position.

    Supervisory status


    Promotion Potential


  • Job family (Series)

    0610 Nurse

This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/522738700. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.