Registered Nurse - Community Care Coordinator

Veterans Health Administration • Wilkes Barre, PA

1d • Onsite

About The Position

The Community Care (CC) Coordinator Registered Nurse (RN) is responsible for executing a streamlined approach to receiving, triaging, and directing timely, coordinated care. The nurse demonstrates proficient practice and decision-making, deliberate planning, and critical thinking skills. The Community Care (CC) Coordinator Registered Nurse (RN) is responsible and accountable for all elements of the nursing process when providing and/or supervising direct patient care. Assesses, plans, implements, and evaluates the effectiveness of the Veteran's care. Serves to support delivery of high quality, timely care to the Veteran receiving services in the community. Assumes responsibility for the coordination of care focused on patient education, self-management, and customer satisfaction throughout the continuum of care. Follows procedures per established policies and guidelines. Influences care outcomes by collaborating with members of the interdisciplinary team. Core elements of performance include knowledge and active participation in the unit/program level quality improvement process and initiatives as well as customer service programs. Executes position responsibilities that demonstrate leadership, experience, and creative approaches to management of complex client care. Additional duties include, but are not limited to: 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 (VA) 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. Works collaboratively within the Office of Integrated Veteran Care (IVC) to triage Request for Services (RFS) to coordinate care processes defined by the IVC Field Guidebook to include developing a care coordination plan, reviewing medical documentation from community providers, communication of care coordination needs, and supporting the Veteran through the completion of the episode of care. Collaborates with members of the interdisciplinary team both within the Veterans Affairs (VA) and in the community. Complies with VA-mandated processes and use of health information solutions that serve to assess, document, exchange, and track care coordination information. Utilizes delegation of authority, if applicable, to function at their highest level of role performance and align high-quality care with key performance indicators to ensure practice standards meet patient care needs. Evaluates outcomes of evidence-based decisions and practice changes for individuals, groups, and populations. Responsible for the documented outcomes at the program or service level. This position may require long periods of sitting through meetings and/or at the computer. Additional duties as assigned.

Requirements

• 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.
• 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.
• 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.
• 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 (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents).
• 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 evaluation.
• 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.
• 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.

Nice To Haves

• VA Community Care, Case Management or Home Health experience.

Responsibilities

• Executing a streamlined approach to receiving, triaging, and directing timely, coordinated care.
• Assessing, planning, implementing, and evaluating the effectiveness of the Veteran's care.
• Supporting the delivery of high quality, timely care to the Veteran receiving services in the community.
• Assuming responsibility for the coordination of care focused on patient education, self-management, and customer satisfaction throughout the continuum of care.
• Following procedures per established policies and guidelines.
• Influencing care outcomes by collaborating with members of the interdisciplinary team.
• Actively participating in the unit/program level quality improvement process and initiatives as well as customer service programs.
• Possessing 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.
• Using 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 (VA) and care in the community.
• Serving as a liaison to both internal and community providers and managing the care of the Veteran throughout the consult process.
• Supporting 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.
• Working collaboratively within the Office of Integrated Veteran Care (IVC) to triage Request for Services (RFS) to coordinate care processes defined by the IVC Field Guidebook to include developing a care coordination plan, reviewing medical documentation from community providers, communication of care coordination needs, and supporting the Veteran through the completion of the episode of care.
• Collaborating with members of the interdisciplinary team both within the Veterans Affairs (VA) and in the community.
• Complying with VA-mandated processes and use of health information solutions that serve to assess, document, exchange, and track care coordination information.
• Utilizing delegation of authority, if applicable, to function at their highest level of role performance and align high-quality care with key performance indicators to ensure practice standards meet patient care needs.
• Evaluating outcomes of evidence-based decisions and practice changes for individuals, groups, and populations.
• Responsible for the documented outcomes at the program or service level.

Benefits

• Competitive salary
• regular salary increases
• potential for performance awards
• 50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year)
• Traditional federal pension (5 years vesting)
• federal 401K with up to 5% in contributions by VA
• Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)
• 1 full and unrestricted license from any US State or territory

What This Job Offers

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