Job Description
Summary The Registered Nurse Remote Patient Monitoring- Home Telehealth Care Coordinators are case managers and health coaches who are highly skilled and have specific training and competency in the use of disease management, health care informatics, and remote patient monitoring technologies. Case management is the cornerstone of Remote Patient Monitoring -Home Telehealth (RPM-HT). Thorough, regular chart reviews and daily monitoring of data are only part of the overall management of care.
Duties Help
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Major Duties: - Practices under the National, VISN 19, and VHASLC local guidelines supported by the Remote Patient Monitoring- Home Telehealth Manual, HT Documentation Clinical User Guide, and the OCC Telehealth Manual.
- Interfaces with a panel of rural or highly rural Veteran patients via computer to monitor daily responses from Veterans' home monitoring input devices.
- Provides initial and ongoing comprehensive assessment, including a review of systems that establish a comprehensive plan of care. T
- Identifies, analyzes, and prioritizes problems and interventions and sets appropriate measurable goals (i.e., Specific, Measurable, Attainable, Realistic, and Timely [SMART] goals). The treatment plan is an extension of the Veteran's primary care plan and is completed in collaboration with PACT, HBPC, mental health care, and other specialty care services, as appropriate for each Veteran enrolled in the program.
- Triages and assesses all data received from RPM - HT patients, such as vital signs, reported symptoms, and question responses.
- Reviews daily responses each workday and contact Veterans about worrisome responses and trends, significant changes in condition, or changes in other specific data elements received, as clinically appropriate.
- Contacts Veterans when responses indicate that an issue may be developing - in order to provide education, offer self-management tips, and assist with problem-solving - rather than waiting until a red alert signals that the situation may be out of control.
- Completes an assessment of patients who may have multiple and complex comorbidities that necessitate additional coordination of care and case management to ensure easily accessible, continuous, high-quality care across all settings.
- Provides ongoing professional assessment and case management to an adult population of predominantly (but not limited to) older male patients.
- Completes assessment and plan of care on assigned patients and provides individualized nursing care.
- Conducts ongoing reassessments to evaluate changes in patients' status.
- Identifies and intervenes to address potential exacerbations or complications in order to facilitate timely care in a clinic, emergency response urgent care setting, or care in the community.
- Provides appropriate interventions, such as medication management, case management, and patient education. Completing protocol-based interventions as needed.
- Triages incoming calls and concerns of Veterans or families, resolving those within their scope of practice, and routing others to interdisciplinary team staff or other services, as indicated.
- Provides interdisciplinary consultation and interventions, such as with Home Based Primary Care (HBPC) and others on institutional care programs and venues, mental health, social work, pharmacy, nutrition, etc.
- Identifies patient knowledge, health factors, skills, and behaviors that support self management and identifying gaps.
- Provides health coaching, patient education, and psychosocial support.
- Provides support and guidance and reviewing changes in medications, goals, and the treatment plan with Veterans during and after transitions in care, such as after a hospital discharge.
- Plans for discharge/transfer of patients, including completing discharge/transfer notes in CPRS.
- Monitors recovery process and related medical, physical, and psychological problems and other interventions defined by unit policy.
- Seeks to improve work processes continuously and offer suggestions for the improvement of patient care.
- Acts as a preceptor/mentor to newer staff and/or students.
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 0800-1630
Telework: Authorized for telework-situational (ad-hoc emergency only) AND has not been authorized as remote.
Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not authorized
Permanent Change of Station (PCS) : Not Authorized
Requirements Help
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, driver's 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 master's level bridge program in nursing who have completed coursework equivalent to a bachelor's 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:
Grade/Level Scope Education Nurse I, Level I
Delivers 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 II
Demonstrates 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 III
Demonstrates 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 Master's degree in nursing (MSN) and no additional professional nursing experience;
OR a Master's degree in a *related field with a BSN and no additional professional nursing experience.
Nurse II
Demonstrates 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 Master's 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 III
Executes 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 Master's 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.
Reference: For more information on this qualification standard, please visit
Preferred Experience: - 2 plus years of nursing experience in an outpatient and/or medical unit, such as ED or Medical Surgical
Physical Requirements: The incumbent must be able to perform all activities of the position without restriction. This position involves considerable standing, walking, stooping, bending, reaching, lifting and turning. It requires repositioning patients and assisting with transferring patients to wheelchairs/stretchers. Mechanical devices when available are required to be used for heavy or difficult to lift patients. The work may involve pushing or lifting weight in excess of 50 pounds and going up and down flights of stairs. The position requires visual and auditory acuity at a level to provide safe and effective nursing care. The positions requires the nurse to work for periods of time with arms above shoulder level or with the neck in a fully flexed or extended position and the ability to physically control or protect him/herself from physically abusive patients.
Additional information This job opportunity announcement may be used to fill additional vacancies.
This position is in the Excepted Service and does not confer competitive status.
VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority.
If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement.
Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.
Candidates should be committed to improving the efficiency of the Federal government, passionate about the ideals of our American republic, and committed to upholding the rule of law and the United States Constitution.
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Job Tags
Permanent employment, Full time, Temporary work, Part time, Seasonal work, Local area, Relocation package, Monday to Friday, Flexible hours,