Registered Nurse (Care Manager)- Home Based Primary Care

Veterans Health Administration • Spokane, WA

17h • Onsite

About The Position

The RN Case Manager provides comprehensive, patient-centered nursing care to Veterans in their homes through the Home Based Primary Care (HBPC) program. The role supports Veterans with complex healthcare needs by promoting independence, improving quality of life, and coordinating comprehensive care in collaboration with an interdisciplinary team. The RN supports Veterans and their families throughout the continuum of care.

The nurse provides direct care and care coordination, including case management, assessment, triage, Veteran education, resource coordination, medication and treatment coordination, and care planning. The position plans and delivers technically competent home-based care that may include health promotion and prevention, geriatric care, primary care, and palliative care. The RN makes home visits, administers medications and procedures under established policies, delegates appropriate care tasks, and collaborates with the interdisciplinary team to influence care outcomes. Interventions are intended to maximize health capabilities and reduce unnecessary urgent care and emergency room visits in accordance with Veterans’ goals of care.

The position is scheduled Monday through Friday, 8:00 a.m. to 4:30 p.m. Compressed or flexible scheduling may be authorized. Telework is not available, and the position is not virtual. Relocation and recruitment incentives and permanent change of station are not authorized.

Requirements

• Proficiency in basic written and spoken English.
• Graduation from an approved school of professional nursing accredited by ACEN or CCNE, or qualifying nursing education under the stated bridge-program or foreign-education provisions.
• Current, full, active, and unrestricted registered nurse licensure in a U.S. State, Territory, Commonwealth, or the District of Columbia; the stated Graduate Nurse Technician exception may apply to eligible candidates pursuing licensure.
• Meet the education and professional nursing experience criteria for the applicable Nurse grade and level.
• Ability to meet the position’s physical requirements, including lifting, carrying, pushing, reaching, walking, standing, kneeling, bending, operating a motor vehicle, and specified vision, coordination, color-discrimination, and hearing abilities.
• U.S. citizenship, except where appointment of a non-citizen is permitted under VA policy.
• Pass required pre-employment screening, including urinalysis for applicants tentatively selected for testing-designated positions, background/security investigation, and pre-employment physical examination.
• Register for Selective Service if applicable to male applicants born after December 31, 1959.
• Participate in the seasonal influenza vaccination program for VA Health Care Personnel.
• Complete the required online onboarding and application requirements.

Nice To Haves

• Registered nurse experience in home health, home-based primary care, community or public health nursing, case management, or ambulatory primary care.
• Experience caring for older adults and Veterans with multiple chronic conditions, dementia, and functional decline, including palliative and end-of-life care.
• Experience managing a defined caseload, including care planning, care coordination, and follow-up after emergency department visits and hospital discharges.
• Experience with medication reconciliation and management for patients on complex medication regimens.
• Experience with phlebotomy and point-of-care testing, injections, and immunizations.
• Experience in wound care, including pressure injury assessment and staging; indwelling and suprapubic catheter care; and ostomy care.
• Experience with telephone triage and virtual care, including VA Video Connect or similar telehealth.
• Ability to practice independently in the community, including working alone, managing a daily visit route, and using sound judgment in home settings.
• Experience working on interdisciplinary teams with providers, social work, rehabilitation, nutrition, pharmacy, and psychology.
• Valid driver’s license and comfort driving rural roads and in winter conditions.
• Bachelor of Science in Nursing (BSN).
• Certification such as Certified Case Manager (CCM), Gerontological Nursing (GERO-BC), Hospice and Palliative (CHPN), Home Health, or wound care.

Responsibilities

• Provide direct Veteran care and care coordination within the Home Based Primary Care program.
• Manage cases, including assessment, triage, Veteran education, resource coordination, medication and treatment coordination, and care planning.
• Plan and deliver technically competent care in Veterans’ homes, including health promotion, health prevention, geriatric care, primary care, and palliative care.
• Use interventions that maximize health capabilities and reduce unnecessary urgent care and emergency room visits in accordance with each Veteran’s goals of care.
• Make home visits to Veterans enrolled in the program.
• Seek guidance on improving care for patients and families.
• Delegate care tasks to appropriate individuals based on assessed needs, condition, and patient safety.
• Administer medications and procedures according to established policies and guidelines.
• Collaborate with interdisciplinary team members to influence care outcomes.
• Remain accountable for individual nursing practice and determine appropriate delegation consistent with the obligation to provide optimal outpatient care.

Benefits

• Competitive salary, regular salary increases, and potential performance awards.
• 50 days of paid time off per year: 26 days of annual leave, 13 days of sick leave, and 11 paid Federal holidays.
• Traditional federal pension with five-year vesting and federal 401(k) with up to 5% in contributions by VA.
• Federal health, vision, dental, term life, and long-term care insurance; many federal insurance programs can be carried into retirement.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree