The Referral Coordination Team Nurse works with Primary Care, Specialty Services, and Community Care to coordinate specialty services for the veteran population. The incumbent is a professional Registered Nurse who is accountable for indirect and direct patient care by demonstrating leadership in delivering and providing holistic care through collaborative strategies with all disciplines for Veterans in Wilmington VA Medical Center. Duties and or responsibilities of the Referral Coordination Team Nurse may include but are not limited to the following: Utilizes motivational interviewing techniques and partners with Veteran to guide them towards an improved quality of life. Works collaboratively with interdisciplinary team members at all points of care, to include but not limited to Primary Care, Specialty Care, Mental Health Care, Acute Care, Social Services, and Care in the Community to improve the transitioning care and health outcomes. Exhibits excellent relationship skills that facilitate communicating Veterans' needs, appropriate level of care, and barriers related to throughput with all members of the healthcare team. Coordinates the plan of care by: placing and acting on consults as appropriate, assisting with appointment utilization, ordering appropriate supplies, monitoring clinical data. Acts as a resource for the development of policy and procedure related to the care of Veteran populations. Serves as a consultant to the PACT teams and Integrated Case Management teams on Specialty care strategies, in efforts to optimize access and strengthen quality of care for Veterans served. Works closely with other VA Medical Centers, contracted facilities and community facilities to remove obstacles that would impede the Veteran from utilizing the services of other VA medical centers or community not available at our facility. Establishes effective networking relationships with peers and professionals within the community as related to Referral Coordination. Receives alerts for new patient consults, assists with ordering and coordinating appropriate tests, obtaining outside reports and communications with the referring provider, private institutions, and physicians, to expedite patient appointments. Collaborates with clinic staff to ensure patients are given timely appointments and expedite new patient consults. Collaborates with specialty nurses and providers both within the facility and at other network facilities to ensure comprehensive understanding of specialty availability and capability. Provides support to providers daily: coordinating dual care with other VA facilities; ensuring all needed records, tests and other information is available to provider at time of consultation to allow provider to focus on treatment plan and Veteran's questions in an appropriate and timely manner. Participates in the development and implementation of recommended policies and procedures as related to Referral Coordination. Maintains and upgrades own knowledge base and skills regarding Referral Coordination and/or specific clinical areas and applies this knowledge to nursing practice. Serves as a resource for other team members and participates in planning for program improvements at the local level. PREFERRED EXPERIENCE: BSN preferred. Outpatient Specialty / Primary Care experience preferred. At least 5 years of RN experience (broad RN background is helpful). Excellent communication and organizational skills preferred. ANCC certification preferred: Ambulatory Care, Nursing Care Management, or Care Coordination and Transition Management. Work Schedule: Monday - Friday: 08:00 AM - 04:30PM. 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.