Registered Nurse- Spinal Cord Injury/Disease (SCI/D) Integrated Case Manager

Veterans Health Administration • Long Beach, CA

1d • Onsite

About The Position

The Registered Nurse Case Manager reports to the Chief of Spinal Cord Injury Service. The role provides comprehensive case management and care coordination to Veterans across inpatient, outpatient, and home-based settings. It has dual responsibilities for coordinating and overseeing Home Healthcare services, outpatient Annual Examinations, and other assigned case management activities. The Case Manager works collaboratively with Veterans, families and caregivers, providers, social workers, nursing staff, and other interdisciplinary team members to support continuity of care, timely access to services, and safe transitions between healthcare settings.

The position includes assessing Veterans’ medical, functional, psychosocial, environmental, and support-system needs; developing and monitoring individualized care plans; coordinating referrals and services; identifying barriers to care and helping resolve them; and ensuring appropriate follow-up. The Case Manager also provides education to Veterans and caregivers, documents care coordination activities in the electronic health record, participates in interdisciplinary meetings and quality-improvement work, and monitors program requirements, performance measures, and documentation standards.

The work schedule is Monday through Friday, 7:00 a.m. to 3:30 p.m. Compressed or flexible scheduling may be considered for highly qualified candidates. 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 appropriately accredited school of professional nursing, or an applicable qualifying nursing education pathway described in the announcement.
• Current, full, active, and unrestricted registered nurse licensure in a U.S. state, territory, or commonwealth, or the District of Columbia; a Graduate Nurse Technician exception may apply to otherwise qualified candidates pursuing licensure.
• Meet the education, experience, and dimension criteria applicable to the assigned Nurse grade and level.
• U.S. citizenship, except where appointment of a non-citizen is permitted under VA policy.
• Successful completion of required pre-employment screening, including a drug test for testing-designated positions, background/security investigation, and physical evaluation.
• Participation in the seasonal influenza vaccination program.
• Meet Selective Service registration requirements where applicable.

Nice To Haves

• Case Management (CCM) board certification.
• Master of Science in Nursing (MSN).
• Two to three years of case management experience in SCI/D or rehabilitation settings.
• Flexibility, self-direction, organization, strong clinical skills, customer-service orientation, and comfort working across multiple care settings.

Responsibilities

• Coordinate and manage Home Healthcare services for eligible Veterans, including needs assessments, service coordination, follow-up, and communication with healthcare providers.
• Conduct and/or coordinate outpatient Annual Examinations and ensure required evaluations and follow-up needs are addressed.
• Assess Veterans’ medical, functional, psychosocial, environmental, and support-system needs.
• Develop, implement, monitor, and update individualized care plans.
• Coordinate referrals and services with VA programs, community resources, specialty services, and other healthcare agencies.
• Facilitate communication among Veterans, caregivers, providers, and interdisciplinary team members.
• Identify barriers to care, discharge, service access, and continuity of care, and help develop solutions.
• Monitor Veterans requiring ongoing case management and ensure appropriate follow-up.
• Educate Veterans and caregivers about available healthcare services, resources, and care plans.
• Document assessments, interventions, coordination activities, and outcomes accurately and promptly in the electronic health record.
• Participate in interdisciplinary team meetings, case conferences, huddles, and quality-improvement activities.
• Monitor program requirements, performance measures, and documentation standards.
• Assist with process-improvement initiatives to improve Veteran outcomes, access, patient flow, and continuity of care.

Benefits

• Competitive salary, regular salary increases, and potential performance awards.
• 50 days of paid time off per year, consisting of 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
• Education Level: Associate degree