James A Haley VA medical center has a current vacancy for a Community Nursing Home Coordinator RN position. This position reports under the Nursing GEC department. Duties Provides patient management, care coordination, and discharge/disposition planning for inpatient and outpatient settings. assists Veterans, family members, and caregivers with receiving the most appropriate options and services to meet their complex health care needs. This includes, but is not limited to, acute, chronic, multiple, complex, catastrophic, or life-threatening illnesses; combat stress, residuals of traumatic brain injury; community adjustment; addictions and other health problems. Coordinates care with multiple providers across all levels and sites of care. Coordination includes assuring services interface within the Veterans Affairs (VA) and CNH programs to provide continuity of care to patients. performs clinical nursing review of medical records of patients who are hospitalized in non-VA hospitals to determine point of stability for payment purposes and potential for transfer of the Veteran to a VA facility for care. Possesses knowledge of utilization management processes, clinical documentation requirements, current standards of care, and compliance guidelines. Maximizes third-party payments for care and delivering quality patient care performance improvement activities. develops and coordinates seamless transitioning of patients throughout the inpatient and outpatient care process with a focus on discharge planning needs. Reviews and assists in patient referrals to CNH facilities to ensure continuity of qualified comprehensive care. Participates as needed in the discharge planning assessment and implementation of community health services, to include skilled nursing care, hospice, adult day health services, respite services and activities required to successful transition the patient to the appropriate non-acute care setting. Performs follow-up and oversight visits to the Veteran after admission to the CNH to ensure that adequate and safe care is being provided while under VA contract. Advocates for holistic care through patient/family education and provider interaction and implements an educational plan to meet the patient care needs.
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Job Type
Full-time
Career Level
Entry Level
Education Level
Associate degree