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.

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. 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.