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    The Transition Care Management Program Nurse (TCM RN) is responsible for acquiring and demonstrating clinical expertise and knowledge of health care programs to improve the quality of patient care, the use of resources, and to facilitate compliance with internal and external requirements and standards; acquiring and demonstrating strength in the areas of interpersonal relations, critical thinking, problem solving, and conflict resolution; collaborating with other Case Managers.

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    Competencies will be demonstrated and sustained with expertise and broad-based clinical knowledge to effectively assess and manage the needs of returning Veterans. The TCM RN will work closely with other Transition Care Management staff, Interdisciplinary team, as well as other healthcare professionals in planning, implementing and evaluating care. The TCM RN provides leadership in delivering holistic care through collaborative strategies with others. Duties include but are not limited to:

    Ensuring initial and on-going assessments of patients to identify needs, issues, resources and care goals are provided in a timely manner.
    Ensures patient health education needs are identified, and education and teaching, as per identified needs, is provided to patients and family as appropriate.
    Ensures care-related goals, both short-term and long-term, are set and agreed upon by the primary provider, patient, and identified family.
    Ensures the patient is screened for social service needs, home care, and other community care needs, and that referrals are coordinated and made as necessary and appropriate by the responsible discipline.
    Demonstrate clinical evidenced-based services and interventions and ability to provide education and consultation to Veterans and staff on nursing issues.
    Coordinate with other members of TCM team, as well as other healthcare professionals in assessing, planning and initiating appropriate care.
    Initiate methods to monitor patients' progress and maintain appropriate documentation. May be assigned additional duties, as indicated by the TCM Program Supervisor, which support the mission and goals of the TCM Program.

    Work Schedule: 7:30 am - 4:00 pm or 8:00 am to 4:30 pm, Monday through Friday
    Financial Disclosure Report: Not required

    NOTE: This position is being advertised under two different disciplines, and area of consideration is for internal and external applicants.
    Announcements for INTERNAL applicants are: Social Worker: VIN: 10688012, Registered Nurse: VIN: 10688014.

    Announcements for EXTERNAL applicants are: Social Worker: VIN: 10688013, Registered Nurse: VIN: 10688015.

    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/555590300. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.