VA Greater Los Angeles Healthcare System (VAGLAHS) is seeking to hire experienced Registered Nurses to work in our Case Management/Care Coordination Program. The Case Manager provides patient centered care with expertise in the coordination of care for high risk clients in the outpatient/inpatient setting ensuring that Veteran-centered health care is provided and delivered in a quality, accessible and respectful manner, consistent with the mission, goals and objectives of the organization. Job duties include, but are not limited to, the following Assesses the patients case management needs. Provides support to the Treatment Team by coordinating the healthcare plan of patients. Participates in team rounds to provide efficient care management of patients. Identifies problems to be resolved through physician action, nursing action, or appropriate interdisciplinary referral. Provides direct patient care/case management and educational patient visits with documentation (in the electronic medical record) of patient responses to care in a clear, concise manner. Provides mentoring/instruction to students on case management. Identifies system problems/barriers, which may inhibit patient access to appropriate care or expedites movement through the system. Conducts utilization review activities as needed and supports research and quality improvement activities. Interacts with family and/or significant others to facilitate patient care and discharge planning including appropriate patent education. Serves as a consultant and resource person to the treatment team, nursing staff, and other healthcare disciplines. Collaborates with the outside facilities if indicated and appropriate VA staff to formulate and implement comprehensive plans for care. Coordinates care for patients with Interfacility Consults (IFCs) from referring facilities. Works with the appropriate subspecialties to ensure appropriate medical information is available for evaluation. Ensures IFCs are addressed in a timely manner in accordance with Advanced Clinical Access principles. Tracks referrals in an approved database. Works directly with providers to ensure high risk patients are monitored appropriately via visits, phone calls, or trans-telephonic means. Obtains appropriate outside records& documents them in CPRS. Facilitates medical and surgical work-up and evaluation as indicated. Works with Attendings/Residents/NP/PA in following specific patients as needed for specific situations or medical conditions. Assists designated clinic in achieving ACA principles. Works toward the goals of a high reliability organization. Collaborates with PACT teams to ensure PCP assignment and follow up. Collaborates with PACT teams to ensure communication regarding patient care needs. Adheres to VHA Integrated Case Management Standards of Care. Adheres to InterQual Criteria. Provides coverage in the Case Management Program based on patient care needs. Collaborates with Care In the Community Program. Work Schedule: Monday-Friday 8:00am to 4:30pm Compressed/Flexible: Not Available Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.