The RN Care Coordinator uses the nursing process and evidence-based practice to collaborate with the PACT team members (Patient, MSCC Provider, Medical Support Assistant (MSA), and LPN) and larger Team (family/caregiver, internal and community-based services) in developing the patient-driven holistic care plans. He/She is responsible for collaborating with services internal and external to the VA to facilitate transition of care that effectively meet the patients' needs. Duties include but are not limited to: - Coordination of the patient's journey through the health care system, across disciplines and sites. - Anticipates, identifies and helps patients to overcome barriers within the VA healthcare systems. - Assists in coordination of healthcare services and referrals. - Serves as patient advocate and direct liaison with physician and other healthcare providers, such as radiology, pathology, mental health and other sub specialty services, including unique VA healthcare system benefits. - Facilitation and coordination of non-VA care referrals and consults. - Maintains awareness of patient's plan of care and communicates as necessary issues that arise, to prevent unnecessary delays in treatment, including missed appointments. - Facilitates acquisition of medical records and diagnostic testing to ensure timely delivery of services. - Expedites consults as per physician instructions in coordination with the referral team. - Active involvement in Endocrinology clinics, participates in new consults with physicians and education as indicated for diagnostic procedures and treatment plan. - Assesses patients to identify needs, issues, and care goals in order to identify resources and critical factors for achieving desired outcomes of care. - Educates patient and/or family on specific needs that will facilitate their participation in the plan of care. Work Schedule: Monday - Friday, normal business hours 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.