Registered Nurse- Care Coordination and Integrated Case Management

CCICM RN Position

The primary function of the CCICM RN is to provide coordination and direct clinical evidence-based services including assessments and interventions; program development; Veteran, family, caregiver and staff education on Care Coordination and Integrated Case Management (CCICM); resource development; community outreach; continuous quality improvement activities, and evaluation/consultation. Duties include, but are not limited to:

• Serves as a CCICM subject matter expert.
• Participates in the development of policies, procedures, and practice guidelines for the program and participates in facility, VISN, and national program development as related to CCICM.
• Ensures compliance with VHA Directive 1110.04, Integrated Case Management Standards of Practice.
• Provides guidance and support in the implementation and maintenance of the program through education, training, mentorship, and coaching.
• Participates in the development of, and implements policies and procedures specific to the Aleda E. Lutz VA Medical Center and ensures compliance with local facility, VISN, Patient Experience Initiatives, VA Central Office (VACO) directives and handbooks, as well as Joint Commission, and other accrediting bodies and regulatory standards as needed.
• Ensures full collaboration with social work counterpart, for all planning, development, implementation, monitoring, and evaluation of the CCICM operations.
• Manages, monitors, evaluates and reports on all CCICM related data to fully capture the day-to-day functioning and practice impacts on the facility and Veteran care.
• Plans, organizes, and directs CCICM operations, in conjunction with the CCICM Executive Sponsor, social work counterpart(s) and the ADPCS.
• Identifies Veteran cohorts across the Aleda E. Lutz VA Medical Center with the highest opportunity and highest need. Including development and implementation of a monitoring process for ongoing screening and identified cohort(s).
• Identifies and tracks potential areas where care coordination is taking place to include but not limited to primary care, surgical care, mental health, community care, specialty clinics, geriatrics, chronic disease, and homeless programs.
• Ensures integration with the facility level care coordination and case management teams to include but not limited to Nurses and Social Workers, care coordinators, care managers, and case managers of, both inpatient and outpatient for seamless continuity of care.
• Develops, implements and tracks facility wide CCICM education plan to key stakeholders to include Service Chiefs, supervisors/managers, frontline staff, and Veterans with plan for ongoing sustainment.
• Develops, implement, and monitor processes for ongoing screening and identified cohort. Actively participates in the treatment planning process with other disciplines, including involvement in discharge planning with other disciplines and will be responsible for ensuring that discharge plans are executed in a manner that are timely and appropriate.
• Actively participates in unit quality improvement processes and initiatives, as well as Veteran experience/customer service programs and initiatives.
• Develops, maintains effective working relationships with key medical center staff and community agencies to enhance the scope and functioning of Veterans assigned. Ability to develop needed community support and/or resources to ensure the program goals are achieved.
• Provides guidance, education, and direction to the Care Coordination Review Team (CCRT). Ensuring full participation by setting expectations, clear roles, and responsibilities when assigning a Lead Coordinator to Veterans identified as needing moderate or complex care coordination services.
• Provides direct patient care services to identified high utilizer/at-risk Veterans to ensure appropriate services are in place to support the CCICM framework.

Preferred: Candidates in possession of and provide proof of BLS Certification will be considered best qualified. 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: 8:00a- 4:30p, Monday- Friday. Schedule may be subject to change based on the needs of the Agency.

Telework: Not Available

Virtual: This is not a virtual position.

Relocation/Recruitment Incentives: Not Authorized

Permanent Change of Station (PCS): Not Authorized