The Remote Patient Monitoring Home Telehealth Case Manager delivers fundamental knowledge-based care to assigned clients while developing technical skills. Assesses, plans, implements, and evaluates care based on age-specific components. Assumes responsibility for the coordination of care focused on patient education, self management, and customer satisfaction throughout the continuum of care.
Duties include but not limited to: Provides care and counseling of persons in the promotion and maintenance of health and prevention of illness and injury based upon the nursing process which includes systematic data gathering, assessment, appropriate nursing judgment, and evaluation of human responses to actual or potential health problems through such services as case finding, health teaching, health counseling; provision of care supportive to or restorative of life and well-being; and executing medical regimens.
Follows procedures per established policies and guidelines. Influences care outcomes by collaborating with members of the interdisciplinary team. Executes position responsibilities that demonstrate beginning leadership skills and participates in specific HT experiences. Demonstrates creative approaches to the management of aspects of complex patient care. Care will be provided in the least restrictive, most cost-effective manner.
Home Telehealth is a program that applies care and case management principles to coordinate care using health informatics, disease management and HT technologies to facilitate access to care and to improve the health of Veterans with the specific intent of providing the right care, in the right place, at the right time.
Works to improve clinical outcomes and access to care while reducing complications, hospitalizations, and clinic or emergency room visits for Veterans in post-acute care settings and high-risk patients with chronic and mental health disease. Provides initial and ongoing comprehensive assessment to include a review of systems which establishes a comprehensive plan of care.
Triages and assesses all data received from HT patients such as vital signs, reported symptoms and question responses. Identifies and intervenes for potential exacerbations of complications to facilitate timely care in Patient Aligned Care Team (PACT) clinic, Emergency Department (ED)/Urgent Care (UC), and or/care in the community. Provides communication and data exchange with community-based providers when there is co-managed care.
Provides interdisciplinary consultation and interventions such as with Home Based Primary Care (HBPC) and other non-institutional care programs and venues, Mental Health (MH), Social Work (SW), Pharmacy, Nutrition, etc. Identifies patients' knowledge, health factors, skills, and behaviors that support self-management and identify gaps therein. Provides health care coaching, patient education, and motivational counseling.
Communicates and facilitates with the interdisciplinary team regarding progress to goals; patterns or trends of data, symptoms or findings; concerning findings; need for provider assessment and/or interventions. Brings principles and theory with the application of critical thinking skills.
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: Monday-Friday, 0730-1600.
Telework: Ad-hoc. Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized. Permanent Change of Station (PCS): Not Authorized.
eduardo.crespo@va.gov · 904-761-0911
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $72273 – $148502/yr.
This position is eligible for telework.
Applications close on 2026-11-03.
This position is open under the 'Fed Internal Search' hiring path.
Source: USAJOBS.gov — U.S. Federal Government · Retrieved 2026-10-29 · Not affiliated with or endorsed by OPM or USAJOBS.gov
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