Registered Nurse (Community Nursing Home Coordinator)

Job Title

Job Description

Provides patient management, care coordination, and discharge/disposition planning for inpatient and outpatient settings.

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.

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.

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.

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 0730-1600

Telework: Not Authorized

Virtual: This is not a virtual position.

Preferred Experience BSN