Registered Nurse - Case Manager/Care Coordinator

The Community Nursing Home Program RN provides clinical oversight, case management, care coordination, and ongoing communication for Veterans receiving care in contracted community nursing home facilities. The RN is responsible for promoting continuity of care, access to services, appropriate utilization, Veteran safety, and effective transitions across VA and community care settings.

The RN works under the direction of the designated supervisor and collaborates with the Social Worker, Program Coordinator, PACT, nursing home staff, Prosthetics, Care in the Community, Hospice, and other members of the interdisciplinary team to provide coordinated, Veteran-centered care. The RN applies the nursing process by assessing, planning, implementing, and evaluating care based on the Veteran's age, health status, functional needs, psychosocial circumstances, values, culture, and preferences.

Core Responsibilities Visit assigned contracted nursing home facilities every 60 days, alternating visits with the Program Coordinator. Assess enrolled Veterans during facility visits and document each encounter in CPRS. Review the Veteran's medication regimen during facility visits and care coordination activities, including medication reconciliation, indication, effectiveness, adherence, potential adverse effects, duplications, interactions, and clinical changes that may warrant follow-up.

Compare medication information across available VA, nursing home, hospital, specialty, and hospice records, and communicate discrepancies or concerns to the appropriate provider, facility staff, PACT, pharmacist, and other members of the care team. Monitor for medication-related risks, including falls, sedation, hypotension, hypoglycemia, bleeding, adverse drug reactions, and other concerns relevant to the Veteran's condition and care setting.

Ensure medication changes associated with admissions, hospitalizations, returns to the facility, transfers, leaves of absence, and discharges are communicated and documented appropriately. Complete and coordinate required depression screenings and updates to VA contact information at admission and annually. Maintain an accurate and current roster of Veterans enrolled in the program and report discharges to the appropriate team members.

Document facility-status changes-including falls, hospital transfers, returns to the facility, and leaves of absence-in CPRS and notify program staff. Report falls promptly to the Program Coordinator and obtain all relevant clinical and incident details from the nursing home. Coordinate Care in the Community requests by obtaining required clinical documentation, forwarding information to the appropriate team, and documenting requests in CPRS.

Coordinate requests for specialty equipment with nursing home staff, the Veteran's care team, and Prosthetics. Support the hospice contract approval process by coordinating physician reviews, tracking determinations, updating the hospice spreadsheet, and communicating outcomes to appropriate staff. Maintain accurate program records, shared calendars, rosters, spreadsheets, and tracking tools. Coordinate routinely with the Social Worker, Program Coordinator, PACT, nursing home staff, and other relevant clinical and administrative personnel to address medical, functional, psychosocial, caregiver, and care-transition needs.

Identify psychosocial concerns and refer Veterans and families to Social Work for assistance with caregiver support, advance care planning, benefits, community resources, discharge planning, and other supportive services. Provide or coordinate patient and family education, support Veteran self-management when appropriate, and promote active participation in care planning. Administer medications and perform nursing procedures in accordance with established policies, procedures, and clinical guidelines.

Collaborate with the interdisciplinary team to influence care outcomes and support safe, timely, and appropriate transitions of care. Participate in program-level quality-improvement initiatives, performance-monitoring activities, customer-service programs, and other strategies supporting efficient and effective patient management. Pay Scale: NF23 VA offers a comprehensive total rewards package: VA Nurse Total Rewards Pay: Competitive salary, regular salary increases, potential for performance awards Paid Time Off: 50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Licensure: 1 full and unrestricted license from any US State or territory Work Schedule: M-F 0730-1600 or 0800-1630 Telework: Available (Ad-hoc) Virtual: This is not a virtual position.

Relocation/Recruitment Incentives: Not authorized. Permanent Change of Station (PCS): Not authorized. PCS Appraised Value Offer (AVO): Not authorized.

Basic Requirements: 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. 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.

Upon achievement of a State license, the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program. (Reference VA Handbook 5005, Appendix G6); 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.

Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements, but do not possess the required licensure, may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.) NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification.

Grade Determinations: The following Scope, Education and Dimension criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade. The Dimension requirements (Practice, Veteran/Patient Driven Care, Leadership, Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: https://apply.usastaffing.gov/ViewQuestionnaire/13110035.

Grade/Level Scope Education Nurse I, Level I Delivers fundamental, knowledge-based care to assigned clients while developing technical competencies. An Associate Degree (ADN) or Diploma in Nursing, with no additional professional nursing required. Nurse I, Level II Demonstrates integration of biopsychosocial concepts, cognitive skills and technically competent practice in providing care to clients with basic or complex.

An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I, Level 1 ;OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required. Nurse I, Level III Demonstrates proficiency in practice based on conscious and deliberate planning. Self-directed in goal setting for managing complex client situations. An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I, Level 2; OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I, Level 2; OR a Master's degree in nursing (MSN) and no additional professional nursing experience; OR a Master's degree in a *related field with a BSN and no additional professional nursing experience.

Nurse II Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others. A BSN with 2 years of professional nursing equivalent to Nurse I, Level 3; OR an MSN with one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Master's degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Doctoral degree in Nursing with no professional nursing experience; OR a Doctoral degree in a *related field with a BSN with no additional professional nursing experience.

Nurse III Executes position responsibilities that demonstrate leadership, experience and creative approaches to management of complex client care beyond the immediate practice setting. MSN and 2 years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Master's degree in *related field with BSN and two years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III. *Note: Foreign education programs/degrees are not creditable as related degrees.

Preferred Qualifications:- -Experience in long-term care, geriatrics, or community nursing home settings. -Experience coordinating care for Veterans with complex medical, behavioral health, or social needs. -Previous experience working with the VA. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. Physical Requirements: Heavy lifting (45 lbs. and over); Heavy carrying (45 lbs. and over); Straight pulling (up to 8 hours); Pushing (up to 8 hours); Reaching above shoulders; Use of fingers; both hands required; walking (up to 8 hours); standing (up to 8 hours); kneeling (2 to 3 hours); repeated bending (up to 8 hours); both legs required; hearing (aid permitted).