Registered Nurse Community Care Coordinator

<p>The Care Coordination and Transition Registered Nurse delivers knowledge-based care to clients while developing technical skills. Assesses, plans, implements and evaluates care. Assumes responsibility for the coordination of care focused on patient education, self-management, and customer satisfaction throughout the continuum of care. Follows procedures per established policies and guidelines. Influences care outcomes by collaborating with members of the interdisciplinary team.</p><h3>Major Duties</h3><p>Major duties include, but are not limited to: 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. Coordinates care with multiple providers across all levels and sites of care. Coordination also includes assuring services interface within the Veterans Affairs (VA) and community programs to provide continuity of care to patients. Addresses psychosocial, as well as nursing and medical needs of patients and their families/caregivers, through participation with the interdisciplinary care team. Coordinates and expedites care from diagnosis to treatment. Analyzes and manages laboratory and radiology results and provides information to the providers. Utilizes databases to provide population management to track patient care through all episodes of care. Evaluates care and outcomes to ensure timely and appropriate provision of services. Advocates for holistic care through patient/family education and provider interaction and implements an educational plan to meet the patient care needs. Performs other duties as required. 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: Full-time *Schedule to be set by service. Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized</p><h3>Requirements</h3>U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. Selective Service Registration is required for males born after 12/31/1959. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical examination. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). You may be required to serve a probationary period. Complete all application requirements detailed in the "Required Documents" section of this announcement.<h3>Education</h3>IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education. Note: Only education or degrees recognized by the U.S. Department of Education (ACEN or CCNE) from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency (ICD-International Consultants of Delaware icdeval.com) with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.