Responsible and accountable for all elements of the nursing process when providing and/or supervising direct patient care. 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: Remote Patient Monitoring (RMP) Home Telehealth (HT) Registered Nurse (RN) Care Coordinator executes position responsibilities that demonstrates leadership, experience, and creative approaches to the management of complex patient care. Care will be provided in the least restrictive, most cost-effective manner.
HT 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.
The HT RN 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. The HT RN 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. The HT RN 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. Provides peers with informal constructive feedback for improvement. Fosters a safe and supportive environment conducive to the professional development of healthcare professionals.
Contributes professional nursing perspective in discussions with the interdisciplinary team. Partners with others to effect change and produce optimal outcomes. Supports colleagues through knowledge sharing to provide safe, quality nursing care. Shares educational findings, experiences, and ideas with peers. Questions clinical practices for the purpose of providing evidence-based care. Participates in activities and strategies to sustain evidence-based-practice.
Work Schedule: 07:00 -1530 Telework: Ad-hoc at Supervisors discretion Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not authorized Permanent Change of Station (PCS): Not authorized 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
Diana.Bacey@va.gov · 775-328-1470
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $89703 – $166144/yr.
This position is eligible for telework.
Applications close on 2026-10-23.
This position is open under the 'Fed Internal Search' hiring path.
Source: USAJOBS.gov — U.S. Federal Government · Retrieved 2026-10-16 · Not affiliated with or endorsed by OPM or USAJOBS.gov
Apply on official site →