• 2301809

JOB SUMMARY:

In this role you will collaborate with the VDAT health care team to coordinate patient and family interventions across the continuum of care, removing barriers and promoting efficient and effective use of resources. Assists patients and families in establishing patient specific goals, both long term and short term. This position facilitates appropriate follow up care and/or refers patients (within the designated patient population) to the appropriate next level or site of care. You will serve in an advocacy role on behalf of patients, families, and caregivers to ensure safe, equitable healthcare provision. In addition, you will assist in developing and meeting key Pillar outcomes and system improvement goals including financial, satisfaction, and clinical as the nursing component of the care coordination model. You will also assist in the nursing component of developing and meeting key Pillar goals including finance, satisfaction, clinical quality of care, innovation, and growth across the continuum of care.


KEY RESPONSIBILITIES:

• Assesses and identifies patients with complex clinical needs that require a coordinated plan of care.
• Develops case management plan that includes strategies or alternative interventions required to attain optimal patient and family specific outcomes.
• Analyzes progress on the plan of care, identifies variances, and intervenes utilizing process improvement methodologies to remove barriers and progress care.
• Integrates ethical provisions in all areas of the practice.
• Demonstrates leadership skills and acts as the key information and education resource for the interdisciplinary team as related to caring for complex needs and securing appropriate services.
• The responsibilities listed are a general overview of the position and additional duties may be assigned.

TECHNICAL CAPABILITIES:

CASE MANAGEMENT (INTERMEDIATE):- Demonstrates mastery of case management in practical applications for complex clinical care coordination. Possesses sufficient knowledge, training, and experience to be capable of successfully delivering results without requiring support and instruction from others. Able to train and educate by setting the example, giving instruction, providing leadership, and generally raising the level of performance of others while on the job.

RN ACCESS PATIENT EDUCATION (INTERMEDIATE):- Demonstrates mastery of patient education in practical applications of a complex nature. Possesses sufficient knowledge, training, and experience to be capable of successfully delivering patient and family education services without requiring support and instruction from others.

TREATMENT PLANNING (INTERMEDIATE):- Demonstrates mastery of treatment planning and possesses sufficient knowledge, training, and experience to be capable of successfully delivering treatment planning services without requiring support and instruction from others.

NURSING PATIENT ASSESSMENT & EVALUATION (INTERMEDIATE):- Demonstrates mastery of patient assessments and evaluations in practical applications of a difficult nature. Conducts primary care patient interviews and physical examinations. Conducts inquiry with a thorough series of questions when patients state an ailment or complaint in order to accurately identify and elaborate on the problem. Possesses sufficient knowledge, training, and experience to role model and coach less experienced peers.

EVIDENCE-BASED PRACTICE (INTERMEDIATE):- Demonstrates ability to integrate evidence from multiple sources and determine if a practice change should occur. Shares knowledge with peers and other clinical team members independently.

CORE ACCOUNTABILITIES:

• Organizational Impact: Independently delivers on objectives with understanding of how they impact the results of own area/team and other related teams.
• Problem Solving/ Complexity of work: Utilizes multiple sources of data to analyze and resolve complex problems; may take a new perspective on existing solution.
• Breadth of Knowledge: Has advanced knowledge within a professional area and basic knowledge across related areas.
• Team Interaction: Acts as a go-to resource for colleagues with less experience; may lead small project teams.

CORE CAPABILITIES:

SUPPORTING COLLEAGUES (P3):

• Develops Self and Others: Invests time, energy and enthusiasm in developing self/others to help improve performance and gain knowledge in new areas.
• Builds and Maintains Relationships: Maintains regular contact with key colleagues and stakeholders using formal and informal opportunities to expand and strengthen relationships.
• Communicates Effectively: Recognizes group interactions and modifies one's own communication style to suit different situations and audiences.

DELIVERING EXCELLENT SERVICES (P3):

• Serves Others with Compassion: Seeks to understand current and future needs of relevant stakeholders and customizes services to better address them.
• Solves Complex Problems: Approaches problems from different angles; Identifies new possibilities to interpret opportunities and develop concrete solutions.
• Offers Meaningful Advice and Support: Provides ongoing support and coaching in a constructive manner to increase employees' effectiveness.

ENSURING HIGH QUALITY (P3):

• Performs Excellent Work: Engages regularly in formal and informal dialogue about quality; directly addresses quality issues promptly.
• Ensures Continuous Improvement: Applies various learning experiences by looking beyond symptoms to uncover underlying causes of problems and identifies ways to resolve them.
• Fulfills Safety and Regulatory Requirements: Understands all aspects of providing a safe environment and performs routine safety checks to prevent safety hazards from occurring.

MANAGING RESOURCES EFFECTIVELY (P3):

• Demonstrates Accountability: Demonstrates a sense of ownership, focusing on and driving critical issues to closure.
• Stewards Organizational Resources: Applies understanding of the departmental work to effectively manage resources for a department/area.
• Makes Data Driven Decisions: Demonstrates strong understanding of the information or data to identify and elevate opportunities.

FOSTERING INNOVATION (P3):

• Generates New Ideas: Proactively identifies new ideas/opportunities from multiple sources or methods to improve processes beyond conventional approaches.
• Applies Technology: Demonstrates an enthusiasm for learning new technologies, tools, and procedures to address short-term challenges.
• Adapts to Change: Views difficult situations and/or problems as opportunities for improvement; actively embraces change instead of emphasizing negative elements.

Job Requirements:

• Bachelor's of Science in Nursing
• 3 years relevant experience
• Current Registered Nurse License

Licensure, Certification, and/or Registration (LCR): RN License - State of Tennessee

Physical Requirements/Strengths needed & Physical Demands:

• Light Work category requiring exertion up to 20 lbs. of force occasionally and uses negligible amounts of force to move objects.

Movement

• Occasional: Standing: Remaining on one's feet without moving.
• Occasional: Walking: Moving about on foot.
• Occasional: Lifting under 35 lbs: Raising and lowering objects under 35 lbs from one level to another
• Occasional: Lifting over 35 lbs: Raising and lowering objects from one level to another, includes upward pulling over 35 lbs, with help of coworkers or assistive device
• Occasional: Carrying under 35 lbs: Transporting an object holding in hands, arms or shoulders, with help of coworkers or assistive device.
• Occasional: Push/Pull: Exerting force to move objects away from or toward.
• Occasional: Bending/Stooping: Trunk bending downward and forward by bending spine at waist requiring full use of lower extremities and back muscles
• Occasional: Balancing: Maintaining body equilibrium to prevent falling when walking, standing, crouching or maneuvering self, patient and equipment simultaneously while working in large and small spaces
• Occasional: Climbing: Ascending or descending stairs/ramps using feet and legs and/or hands and arms.
• Occasional: Kneeling:Bending legs at knees to come to rest on knee or knees.
• Occasional: Crouching/Squatting: Bending body downward and forward by bending legs and spine.Reaching above shoulders: Extending arms in any direction above shoulders.
• Occasional: Reaching above shoulders: Extending arms in any direction above shoulders.
• Occasional: Handling: Seizing, holding, grasping, turning or otherwise working with hand or hands.
• Occasional: Bimanual Dexterity: Requiring the use of both hands.
• Frequent: Sitting: Remaining in seated position
• Frequent: Reaching below shoulders: Extending arms in any direction below shoulders.
• Frequent: Fingering: Picking, pinching, gripping, working primarily with fingers requiring fine manipulation.

Sensory

• Continuous: Communication: Expressing or exchanging written/verbal/electronic information.
• Continuous: Auditory: Perceiving the variances of sounds, tones and pitches and able to focus on single source of auditory information
• Continuous: Vision: Clarity of near vision at 20 inches or less and far vision at 20 feet or more with depth perception, peripheral vision, color vision.
• Continuous: Smell: Ability to detect and identify odors.

Environmental Conditions

• Occasional: Chemicals and Gasses: Medications, cleaning chemicals, oxygen, other medical gases used in work area.
• Occasional: Pathogens: Risk of exposure to bloodborne pathogens and other contagious illnesses.