Summary

The Community Care RN Care Coordinator is responsible for organizing and directing team members to achieve desired patient outcomes through care coordination and management. The RN Care Coordinator functions in the Office of Community Care which utilizes an Integrated Team model. The RN Care Coordinator uses the nursing process and evidence-based practice to collaborate with the Integrated Team and Provider teams (VA and Community) in developing the patient-driven care plan.

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/12946904
• 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
• Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• Physical Requirements: This position requires visual acuity - keen hearing - clear distinctive speech - and manual dexterity
• This position requires potentially long periods of continued walking - standing - stooping - sitting - bending - pulling - and pushing
• Transferring patients and objects may be required
• Mechanical inpatient lifts are provided
• The incumbent may be exposed to infected patients and contaminated materials and may be required to don protective clothing in isolation situations - operative/invasive procedures - or home settings
• The incumbent may occasionally be exposed to patients who are combative secondary to delirium - dementia - or psychiatric disorders
• The incumbent must be a mature - flexible - sensible individual capable of working effectively in stressful situations - and able to shift priorities based on patient needs
• Must complete annual Employee Health requirements - such as annual TB screening or testing - as a condition of employment
• The incumbent who provides care in home settings or other off-site locations may be required to drive and/or ride in GSA-vehicles.

Duties

• Duties include but are not limited to: Functions directly to support the Local Office of Community Care (LOCC) through clinical review and care coordination of services for Veterans
• Responsible for the planning - integrating - implementing - modifying - and evaluating the effectiveness of the Veteran's care
• Utilizes the LOCC foundational elements to support the delivery of high-quality - timely care to the Veteran receiving services in the Community
• The RN Care Coordinator is the leader of the Integrated Care Team established by the VA Community Care Operating Model
• Provides clinical leadership and expertise on community care processes and regulations
• Serves as the liaison to both internal and external providers and will be responsible for managing and coordinating the care of the Veterans and the seamless transition to and from the community
• Possesses the knowledge related to VHA guidelines - utilization review criteria - current evidence-based standards of care - compliance guidelines - and local policy related to Delegation of Authority as established by the facility Chief of Staff
• Core elements of performance include knowledge and active participation in unit/program level quality improvement processes and initiatives as well as customer service programs
• Primary commitment is to the patient - whether an individual - family - group or community
• Follows standardized care coordination model - incorporating case management principles if applicable - knowledge of processes related to referral and authorization - and secure medical documentation exchange
• Able to identify Veterans requiring disease management and initiates the process to obtain these resources internally or externally to the VA if applicable
• Focuses on providing care that is unique to the Veteran's needs and continues to monitor - track - and intervene - if necessary - in the episode of care across the continuum
• Performs other duties as assigned
• Preferred Experience: Bachelor of Science in Nursing (BSN) Master of Science in Nursing (MSN) 5 years experience preferred working as a Care Manager/Coordinator and/or ICU/medical/surgical setting Demonstrated proficiency and operational knowledge of Electronic Health Records Systems - Outlook - Microsoft Office suite/programs - VA CPRS EHR system - Microsoft Teams - Adobe Strong communication skills and skillset to build partnerships and collaborate across the care continuum 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 Telework: Not Available Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized