RN Care Manager Home Based Primary Care PACT

Home Based Primary Care (HBPC) is an interdisciplinary program that provides short term and long-term health care services to patients who are homebound. The HBPC Registered Nurse (RN) provides comprehensive primary care and case management to veterans at home. The RN works for the Veterans Affairs Palo Alto Health Care System (VAPAHCS) at the Monterey Community Based Outpatient Clinic.

The major duties include but are not limited to:

• Initiates all HBPC admission/discharge forms and assumes responsibility for their completion.
• Alerts administrative/program assistant to admission and discharge of patients.
• Consolidates initial assessments by the appropriate HBPC team members and ensures its completeness in a timely manner.
• Coordinates quarterly reviews of treatment plans.
• Leads patient care discussion in HBPC staff meetings.
• Performs chart audits.
• Contacts appropriate personnel upon admission into HBPC Program and follows patients) during hospitalization of 14 days or less.
• Assessment planning interventions and evaluation of patient problems.
• Documenting and reporting.
• Coordination and management of patient care.
• Implementation of standards of care and practice both Patient Care Services and HBPC Program specific.
• Administration and evaluation of response to ordered treatments and medications.
• Operation and oversight of medical equipment associated with patient care.
• Incorporation of age specific guidelines in the delivery of patient care.

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: Full-time 8:00am-4:30pm Monday-Friday (With flexibility to meet patient needs)
Telework: Not Available
Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not Authorized
EDRP Authorized: Former EDRP participants ineligible to apply for incentive. Contact the EDRP Coordinator for questions/assistance. Learn more
Permanent Change of Station (PCS): Not Authorized

Conditions of employment

• 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 ( Effective May 7 2025 drivers 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 examination.
• 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.

Qualifications

Basic Requirements:

• English Language Proficiency. In accordance with 38 U.S.C. 7403(f) no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English.
• Graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE); OR Individuals attending a masters level bridge program in nursing who have completed coursework equivalent to a bachelors level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program. Upon achievement of a State license the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program. (Reference VA Handbook 5005 Appendix G6); OR In cases of graduates of foreign schools of professional nursing possession of a current full active and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program. Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD).
• Current full active and unrestricted registration as a graduate professional nurse in a State Territory or Commonwealth (i.e. Puerto Rico) of the United States or the District of Columbia. Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements but do not possess the required licensure may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.)

NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification.

Grade Determinations: The following Scope Education and Dimension criteria must be met in determining the grade assignment of candidates and if appropriate the level within a grade. The Dimension requirements (Practice Veteran/Patient Driven Care Leadership Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: I Level IDelivers fundamental knowledge-based care to assigned clients while developing technical competencies.An Associate Degree (ADN) or Diploma in Nursing with no additional professional nursing required.Nurse I Level IIDemonstrates integration of biopsychosocial concepts cognitive skills and technically competent practice in providing care to clients with basic or complex.An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I Level 1 ;OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required.Nurse I Level IIIDemonstrates proficiency in practice based on conscious and deliberate planning. Self-directed in goal setting for managing complex client situations.An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I Level 2; OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I Level 2; OR a Masters degree in nursing (MSN) and no additional professional nursing experience; OR a Masters degree in a *related field with a BSN and no additional professional nursing experience.Nurse IIDemonstrates leadership in delivering and improving holistic care through collaborative strategies with others.A BSN with 2 years of professional nursing equivalent to Nurse I Level 3; OR an MSN with one year of specialized nursing experience equivalent to Nurse I Level 3; OR a Masters degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse I Level 3; OR a Doctoral degree in Nursing with no professional nursing experience; OR a Doctoral degree in a *related field with a BSN with no additional professional nursing experience.Nurse IIIExecutes position responsibilities that demonstrate leadership experience and creative approaches to management of complex client care beyond the immediate practice setting.MSN and 2 years of specialized nursing experience one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Masters degree in *related field with BSN and two years of specialized nursing experience one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III.*Note: Foreign education programs/degrees are not creditable as related degrees.

Preferred Experience:

• 2 years of RN experience
• Experience in Geriatrics Homecare Rehabilitation & Long Term Care

Reference: For more information on this qualification standard please visit Requirements: This position requires heavy lifting 45 pounds heavy carrying 45 pounds straight pulling (2 hours); reaching above shoulder; use of fingers; both hands required; walking & standing 8 hours -intermittently; repeated bending; both legs required; ability for rapid mental& muscular coordination simultaneously; near vision correctable at 13 to 16 to Jaeger 1 to 4; far vision correctable in one eye to 20/20 and to 20/40 in the other; depth perception; ability to distinguish shades of colors; hearing (aide permitted). Transferring patients and objects may be required. The incumbent may be exposed to infected patients and contaminated materials and may be required to don protective clothing in isolation situations or operative/invasive procedures. The incumbent may occasionally be exposed to patients who are combative secondary to delirium dementia or psychiatric disorders. The incumbent must be a mature flexible sensible individual capable of working effectively in stressful situations able to shift priorities based on patient needs.