Specialty Case Management RN

Specialty Case Management Registered Nurse

The Specialty Case Management (CM) Registered Nurse (RN) executes position responsibilities that demonstrate leadership, experience, and creative approaches in providing complex patient management. Provides patient management, care coordination, and discharge/disposition planning for inpatient and outpatient settings. The CM RN 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. The CM RN addresses psychosocial, as well as nursing and medical needs of patients and their families/caregivers, through participation in interdisciplinary patient care management practice. The CM RN also evaluates care and outcomes to ensure timely and appropriate provision of services. Collaborates in the development, implementation, evaluation, and revision of policies, procedures, and/or guidelines. Demonstrates performance and leadership that is broad enough to improve the care for a group of patients. Provides peers with formal or informal constructive feedback for improvement. Supports colleagues and other nurses through CM knowledge sharing to provide safe, quality nursing care. Fosters a safe and supportive environment conducive to the professional development of health care professionals. Evaluates CM outcomes of evidence based decisions and practice changes for individuals, groups, and populations. Responsible for the documented CM outcomes at the program or service level. Program or service level outcomes must be broad and complex and can be demonstrated at any organizational level within a facility. Responsibilities include, but are not limited to:

Operations & care coordination:

• Supports patient care across the health care continuum including inpatient and outpatient operations, including patient flow, appointment management, triage, patient education, monitoring progress toward care goals, and ensuring timely follow-up.
• Participates in patient encounters as part of the interdisciplinary team to help establish and support patient goals of care.
• Uses the nursing process to develop, implement, and evaluate individualized care plans in collaboration with the interdisciplinary team.
• Collaborates closely with the interdisciplinary team to coordinate outpatient treatment plans and support treatment planning decisions.
• Uses a team-based approach to triage and resolve patient care concerns.
• Operates within a dynamic clinical environment requiring consistent physical presence to facilitate timely care coordination, direct patient assessment, and real-time team collaboration. Must demonstrate adaptability and the ability to provide cross-coverage across units or service lines in response to fluctuating patient volumes, staffing needs, or organizational priorities.
• Maintains baseline clinic nurse competency to provide basic clinical coverage when needed to meet operational needs - including patient check-in, routine triage calls, and general patient education - during short-term absences of clinic-based RN staff, consistent with individual competency and scope of practice.

Provider & consult support:

• Provides daily support to providers by coordinating care with community and VA facilities, ensuring necessary records, test results, and information are available for timely consultations and treatment planning.
• Ensures consults are received, reviewed, and appropriately managed (including scheduling, completing e-consults, or discontinuing as appropriate) and works with clinic staff to expedite new patient consults when medically indicated.

Patient communication & access:

• Communicates with patients about their health care options within the VA and community, following eligibility guidelines and national directives.
• Works with VA Medical Centers, contracted partners, and community facilities to address barriers to accessing needed services. Strives to provide a positive patient experience through navigation of the health care system to ensure care needs are met.

Work Schedule: Monday-Friday, 0730-1600

Telework: Not Authorized

EDRP Authorized: Contact View email address on click.appcast.io, the EDRP Coordinator for questions/assistance. Learn more

Relocation/Recruitment Incentives: Not Authorized

Permanent Change of Station (PCS): Not Authorized

Financial Disclosure Report: Not required

US Department of Veterans Affairs