REGISTERED NURSE - COMMUNITY NURSING HOME COORDINATOR

Job Title

Registered Nurse Community Nursing Home (CNH) Coordinator

Job Description

Responsibilities include, but are not limited to the following: The Registered Nurse Community Nursing Home (CNH) Coordinator focus is on individual growth and development in practice with increased levels of self-direction. This nurse brings principles and theory with limited application of critical thinking skills. Provides patient management, care coordination, and discharge/disposition planning for inpatient and outpatient settings. The CNH Coordinator assists Veterans, family members, and caregivers with receiving the most appropriate options and services to meet their complex health care needs. This includes, but is not limited to, acute, chronic, multiple, complex, catastrophic, or life-threatening illnesses; combat stress, residuals of traumatic brain injury; community adjustment; addictions and other health problems. Coordinates care with multiple providers across all levels and sites of care. Coordination includes assuring services interface within the Veterans Affairs (VA) and CNH programs to provide continuity of care to patients. The CNH Coordinator is required to travel routinely to fulfill responsibilities within the Community Care Community Nursing Home (CNH) Program. Travel includes visits to contracted Community Nursing Home facilities for patient assessments, ongoing monitoring, quality assurance reviews, staff education, and collaborative meetings with facility leadership. The nurse may also be required to travel for outreach, training, and coordination activities with internal VA partners and external community providers. Travel may be scheduled or unscheduled based on patient care needs, safety concerns, regulatory requirements, or emergent issues within contracted facilities. The CHN Coordinator must maintain reliable transportation and the ability to travel throughout the CNH service area to ensure timely, comprehensive oversight of Veteran care. The CNH Coordinator performs clinical nursing review of medical records of patients who are hospitalized in non-VA hospitals to determine point of stability for payment purposes and potential for transfer of the Veteran to a VA facility for care. Possesses knowledge of utilization management processes, clinical documentation requirements, current standards of care, and compliance guidelines. Maximizes third-party payments for care and delivering quality patient care performance improvement activities. The CNH Coordinator develops and coordinates seamless transitioning of patients throughout the inpatient and outpatient care process with a focus on discharge planning needs. Reviews and assists in patient referrals to CNH facilities to ensure continuity of qualified comprehensive care. Participates as needed in the discharge planning assessment and implementation of community health services, to include skilled nursing care, hospice, adult day health services, respite services and activities required to successful transition the patient to the appropriate non-acute care setting. Performs follow-up and oversight visits to the Veteran after admission to the CNH to ensure that adequate and safe care is being provided while under VA contract. Advocates for holistic care through patient/family education and provider interaction and implements an educational plan to meet the patient care needs.