Community Care Coordinator Nurse

Summary

Primary Purpose: Delivers fundamental knowledge-based care to assigned clients while developing technical skills. Assesses, plans, implements, and evaluates the effectiveness of the Veteran's care. Service to support delivery of high quality, timely care to the Veteran receiving services in the community. Assumes the responsibility for the coordination of care focused on patient education, self-management, and customer satisfaction throughout the continuum of care.

Duties

Major duties include but are not limited to: Responsible for executing a streamlined approach to receiving, triaging, and directing timely, coordinated care. Brings principles and theory with limited application of critical thinking skills. Possesses intimate knowledge of the internal referral care process, clinical review criteria, utilization management standards, clinical documentation requirements, community care regulations, and Veterans Health Administration (VHA) standards and guidelines. Uses nursing knowledge and systems theory to assess, organize, facilitate, and guide Veterans through their full range of care options including internal/direct care in Veterans Affairs and care in the community. Serves as a liaison to both internal and community providers and is responsible for managing the care of the Veteran throughout the consult process. Supports the medical center's mission to improve timely access to care, ensure Veterans who want to receive care in the community are referred and scheduled into the community , and support the delivery of high quality, timely care to the Veteran receiving community services. Preferred Experience: Three or more years of nursing experience. At least one year in Care Coordination, Case Management, or Utilization Management. The ideal candidate possesses at least one year experience performing the following functions: Leading an integrated care team through providing clinical leadership and expertise on program processes and regulations. Demonstrating effective communication skills to collaborate and co-manage the patient's care with the multidisciplinary team in a cost-effective manner. Serving as lead care coordinator for the patient and following the standardized care coordination model, incorporating case management principles, as applicable. Facilitating care unique to the patients needs, monitoring, tracking, and intervening if necessary in the episode of care across the continuum. Performing clinical review of referrals for specialty care, to include identifying pertinent medical records and diagnostic results to include with referral. Applying knowledge related to policy guidelines, utilization review criteria, and current evidence based standards of care. Reviewing requests for continued care or higher level of care and composing clinical summary of requests to facilitate provider clinical review. 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: Full Time, 0800 - 1630 Telework: Ad-Hoc Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

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: https://apply.usastaffing.gov/ViewQuestionnaire/13076174. 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 throu