Registered Nurse (Community Care Coordinator)

Summary

The Community Care (CC) Nurse is a licensed professional registered nurse assigned to coordinate care for Veterans requesting or referred for community care. The RN is responsible for evaluating care requested as a delegate of authority (DOA) - as established by Chief of Staff - and providing the clinical guidance and expertise for the coordination of community care. This includes assessment - planning - implementing and evaluating care.

Qualifications

Basic Requirements:

• English Language Proficiency
• In accordance with 38 U.S.C. 7403(f) - no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English
• Graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE)
• OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program
• Upon achievement of a State license - the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program
• (Reference VA Handbook 5005 - Appendix G6)
• OR In cases of graduates of foreign schools of professional nursing - possession of a current - full - active - and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program
• Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD)
• Current - full - active - and unrestricted registration as a graduate professional nurse in a State - Territory or Commonwealth (i.e. - Puerto Rico) of the United States - or the District of Columbia
• Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements - but do not possess the required licensure - may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.) NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification
• Grade Determinations: The following Scope - Education and Dimension criteria must be met in determining the grade assignment of candidates - and if appropriate - the level within a grade
• The Dimension requirements (Practice - Veteran/Patient Driven Care - Leadership - Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment:
• Grade/Level Scope Education Nurse I - Level I Delivers fundamental - knowledge-based care to assigned clients while developing technical competencies
• An Associate Degree (ADN) or Diploma in Nursing - with no additional professional nursing required
• Nurse I - Level II Demonstrates integration of biopsychosocial concepts - cognitive skills and technically competent practice in providing care to clients with basic or complex
• An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I - Level 1 ;OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required
• Nurse I - Level III Demonstrates proficiency in practice based on conscious and deliberate planning
• Self-directed in goal setting for managing complex client situations
• An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I - Level 2
• OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I - Level 2
• OR a Master's degree in nursing (MSN) and no additional professional nursing experience
• OR a Master's degree in a *related field with a BSN and no additional professional nursing experience
• Nurse II Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others
• A BSN with 2 years of professional nursing equivalent to Nurse I - Level 3
• OR an MSN with one year of specialized nursing experience equivalent to Nurse I - Level 3
• OR a Master's degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse I - Level 3
• OR a Doctoral degree in Nursing with no professional nursing experience
• OR a Doctoral degree in a *related field with a BSN with no additional professional nursing experience
• Nurse III Executes position responsibilities that demonstrate leadership - experience and creative approaches to management of complex client care beyond the immediate practice setting
• MSN and 2 years of specialized nursing experience - one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Master's degree in *related field with BSN and two years of specialized nursing experience - one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Doctoral degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III
• *Note: Foreign education programs/degrees are not creditable as related degrees
• Preferred Experience: Care navigation & consult management: Skilled in assisting Veterans through care coordination processes
• both VA and community-based
• ensuring adherence to VHA standards and clinical decision-making guidelines
• Community care coordination: Demonstrated ability to manage and triage Community Care consults for clinical appropriateness - including Request for Services (RFS) - patient-centered care coordination
• Strong critical thinking & clinical judgment: Proven ability to apply nursing knowledge and systems theory to assess - plan - coordinate - and evaluate care - ensuring high-quality - timely outcomes
• Interdisciplinary collaboration: Experience working with multidisciplinary teams (e.g. - integrated veteran care - RCI - medical center staff - community providers) to facilitate efficient - quality-driven patient care
• Health information systems proficiency: Proficient in computer systems and technology
• adapt quickly to new software and tools such as VA-specific systems and Microsoft Office Suite
• Reference: For more information on this qualification standard - please visit
• Physical Requirements: The incumbent must be able to perform all activities of the position without restriction
• This position involves considerable standing - walking - stooping - bending - reaching - lifting and turning
• It requires repositioning patients and assisting with transferring patients to wheelchairs/stretchers
• Mechanical devices when available are required to be used for heavy or difficult to lift patients
• The work may involve pushing or lifting weight in excess of 50 pounds and going up and down flights of stairs
• The position requires visual and auditory acuity at a level to provide safe and effective nursing care
• The positions requires the nurse to work for periods of time with arms above shoulder level or with the neck in a fully flexed or extended position and the ability to physically control or protect him/herself from physically abusive patients.

Duties

• Duties and responsibilities include - but are not limited to - the following: Utilize multiple approved resources including: CPRS - Consult Tracking Manager (CTM) - Consult Toolbox (CTB) - JLV (Joint Legacy Viewer) - Virtru Pro - Scanning - Vista Imaging Display - Vista Imaging Capture - External Provider Scheduling (EPS) - Enterprise Precision Scanning and Indexing (EPSI) - Provider Profile Management System (PPMS) - HSRM - Bizcom - ECfax - Milliman Care Guidelines (MCG) - TriWest Portal and associated program guidebook(s)
• Review and evaluate community care care requests as a delegate of authority (DOA) - as established by Chief of Staff - for specific categories of care
• Review supporting documentation for medical appropriateness and completeness - and authorize or deny requests
• Verify the veteran's enrollment status - and place an enrollment LEAF request as needed when veteran is listed as \"Not Enrolled\" or \"In Progress\" Determine the most appropriate Standardized Episodes of Care (SEOC) for a consult - can clearly outline the consult authorization coverage and specific relevant limitations - and is able to explain these details to the veteran effectively Utilize the DST through Consult Toolbox to determine Community Care eligibility as outlined in the Mission Act and IVC Field Guidebook
• Utilize Care Management Tool (CMT) for complex care coordination along with coordination with VA providers and community provider
• Review incoming records from the community providers for medical appropriateness - completeness and significant findings
• Assure scanned results are placed in medical record and attached to the associated consults
• Speak with veterans and be a resource for helping veterans understand care or treatments as well as the expected process for community care
• Act as a resource of knowledge for the community care process for fellow VA staff
• Coordinate care with Internal VA Specialty Providers and/or Primary Care teams on consults and veteran needs
• Coordinate care with the Community Care LIPs
• Collaborate with other health care team members and staff (social workers - travel team etc.) to facilitate complete care of the veteran
• Educate and train incoming CC Nurse staff
• Appropriately documents nursing evaluations - assessment and interventions in medical record
• Maintain a flexible work environment to the changing needs of the office workload and patient needs
• Base care on current evidenced based - best practice standards - knowledge/technological advances and/or research findings
• Knowledgeable of the federal regulations for Community Care - VHA - Guidelines - and care management processes
• Identify personal learning needs and assume responsibility for own professional growth
• Advocate fiscal responsibility in the management of patient care through effective utilization of resources
• Maintain a working knowledge of resources available in the community
• Participate in quality improvement activities
• Schedule Veteran appointments - generate authorizations utilizing scheduling software (ex
• HSRM - RefDoc etc.) and communicate with both Veteran and community provider to coordinate appointment
• 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: 8:00 A.M
• - 4:30 P.M
• Monday - Friday Telework: Available
• The Veterans Health Administration - including VISN 19 and the VA Salt Lake City Health Care System - will comply fully with the intention and instructions contained in the \"Return to Office\" Executive Order
• This position will likely be eligible to telework on a limited Ad-Hoc basis only
• 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

The Veterans Health Administration (VHA) is the largest integrated health care system in the United States, providing care at 1,321 health care facilities, including 172 VA Medical Centers and 1,138 outpatient sites of care of varying complexity (VHA outpatient clinics) to over 9 million Veterans enrolled in the VA health care program. VHA Medical Centers provide a wide range of services including traditional hospital-based services such as surgery, critical care, mental health, orthopedics, pharmacy, radiology and physical therapy. In addition, most of our medical centers offer additional medical and surgical specialty services including audiology & speech pathology, dermatology, dental, geriatrics, neurology, oncology, podiatry, prosthetics, urology, and vision care. Some medical centers also offer advanced services such as organ transplants and plastic surgery.