Summary The Community Care Case Manager RN is responsible for executing a streamlined approach to receiving, triaging, and directing timely, coordinated care. The RN Brings principles and theory with application of critical thinking skills. 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. Responsibilities Major Duties include but are not limited to: Assesses, plans, implements, and evaluates the effectiveness of the Veteran's care Follows procedures per established policies and guidelines Influences care outcomes by collaborating with members of the interdisciplinary team Responsible for executing a streamlined approach to receiving, triaging, and directing timely, coordinated care 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 Work 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 Influence care outcomes by collaborating with members of the interdisciplinary team both within the VA and in the community Comply with VA-mandated processes and use of health information solutions that serve to assess, document, exchange, and track care coordination information Utilize 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 Knowledge of professional nursing practice and the ability to apply the nursing process (assessment, diagnosis, outcome identification, planning, implementation, and evaluation) Completes orientation according to expected standards Responsible and accountable for individual nursing practice and seeks direction from others as needed Manages workload as assigned, organizes, and completes own assignments in an efficient and appropriate manner Participates in the development, implementation, and evaluation of interdisciplinary care Knowledge of Veteran/patient driven care, patient experience, satisfaction, and safety Establishes a therapeutic relationship, allowing the patient to attain, maintain or regain optimal function through assessment and treatment Engages patients, families, and other caregivers to incorporate knowledge, values, and beliefs into care planning without judgement or discrimination Knowledgeable of ethical issues related to professional nursing practice and follows established policies of the practice setting Aware of high reliability principles to deliver consistent care and improve patient outcomes Communicates, collaborates, and utilizes leadership principles to perform as an effective member of the interprofessional team Incorporates educational resources/opportunities and self evaluation for professional growth Participates in unit based educational activities and continuing education requirements. Responsible for maintaining competency to continue personal and professional growth Awareness of evidence-based practice/research to improve quality of care and resource utilization Participates in unit-based activities to improve and deliver cost effective patient care Demonstrates knowledge of specific unit level performance improvement activities Meets the needs of the Veteran and as appropriate the Veteran's family, caregiver and/or significant other, the Veteran's representative, visitors to VA facilities, all VA staff and other customers while supporting VA missions 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: Monday - Friday, 8:00am - 4:30pm Compressed/Flexible: Not Authorized Telework: Not Authorized Virtual: This is not a virtual position Requirements Conditions of Employment 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. Applicants who refuse to be tested will be denied employment with VA. 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. Qualifications 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/13059158. 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 Experience: Case Management experience, minimally 5 years of acute/critical care clinical experience, excellent Verbal and written communication skills, strong problem solving and critical thinking Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. Education Additional Information This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.
