Registered Nurse- Community Care Coordinator

Veterans Health Administration • Minneapolis, MN

1d • Onsite

About The Position

The Community Care Coordinator (CCC) is a registered nurse responsible for care coordination and care management for veterans receiving authorized community care, including clinical triage of moderate and complex cases. The CCC uses clinical knowledge and expertise to review referrals and create care plans for pre-authorized and emergent episodes of care, following Integrated Veteran Care (IVC) guidance. The role requires leadership and innovative approaches to coordinating care in a complex environment.

The CCC coordinates planned and unplanned care with community providers and acts as a liaison between a veteran’s VA PACT or CC-PCP team, Minneapolis VA Health Care System providers and clinics, and non-VA facilities where veterans receive treatment. The position supports safe transitions through nursing interventions, follow-up, education, referral facilitation, and ongoing communication. The CCC also serves as case manager for veterans with Community Care-Primary Care and tracks authorizations to prevent lapses in care.

The position is scheduled Monday through Friday, 7:30 a.m. to 4:00 p.m. Occasional, episodic, or short-term telework may be authorized subject to required training and a telework agreement; this is not a virtual position. A BLS certification is required and may be obtained upon hire.

Requirements

• Graduate of an approved professional nursing program accredited by ACEN or CCNE, or qualifying equivalent nursing education as described in the announcement.
• Current, full, active, and unrestricted registered nurse license in a U.S. state, territory, commonwealth, or the District of Columbia; a temporary Graduate Nurse Technician appointment may be available to otherwise qualified candidates actively pursuing licensure.
• Proficiency in basic written and spoken English.
• BLS certification is required; it may be obtained upon hire.
• Ability to meet the position's grade-specific education and nursing experience criteria.
• U.S. citizenship, except that non-citizens may be appointed when qualified citizens cannot be recruited under VA policy.
• Selected applicants must meet applicable pre-employment screening, identification, background/security, physical evaluation, onboarding, and seasonal influenza vaccination requirements.

Nice To Haves

• Three to five years of recent RN experience in care coordination, case management, population health, community care, primary care, ambulatory care, chronic disease management, or transitions of care.
• Experience coordinating care for complex patients with multiple chronic conditions, behavioral health needs, and social determinants of health concerns.
• Experience developing and implementing individualized care plans, including assessment, care coordination interventions, outcome monitoring, and care transitions.
• Knowledge of evidence-based guidelines, chronic disease management, motivational interviewing, and patient education.
• Demonstrated ability to manage a large caseload while meeting quality, timeliness, and documentation standards.

Responsibilities

• Review referrals and develop care plans for pre-authorized and emergent episodes of care in accordance with Integrated Veteran Care guidance.
• Triage patient needs and collaborate with the care team to identify, analyze, and resolve patient care problems.
• Coordinate planned and unplanned veteran care with selected community providers to support safe, effective, equitable, and efficient care.
• Serve as a liaison among veterans’ VA PACT or CC-PCP teams, VA providers and clinics, and non-VA facilities where veterans are hospitalized or treated.
• Coordinate transitions of care using nursing interventions and thorough follow-up efforts.
• Respond to phone messages, faxes, and alerts in a timely manner.
• Contact veterans by phone, letter, or email regarding their care plans.
• Educate veterans about care progression and appropriate levels of care to support safe transitions.
• Serve as case manager for veterans receiving Community Care-Primary Care.
• Maintain communication and track authorizations to prevent lapses in care, anticipating care coordination needs.
• Facilitate referrals and recommendations that support ongoing veteran needs.
• Maintain confidentiality of patient and employee information in electronic, verbal, and written communications.
• Communicate and interact courteously with internal and external customers.
• Demonstrate professional communication, conduct, leadership, adaptability, and willingness to accept increasing accountability.

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.
• 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: Mid Level
• Education Level: Associate degree