Nurse SCI/D Integrated Case Manager - Care Coordination

Veterans Health Administration; Long Beach (CA); On-site; USD 114,000 - 195,000; Full time

Job summary

Veterans Health Administration in Long Beach, CA, seeks a Registered Nurse- Spinal Cord Injury/Disease Integrated Case Manager to coordinate comprehensive case management for Veterans across inpatient, outpatient, and home-based settings.

The role emphasizes coordination of Home Healthcare, outpatient Annual Examinations, development of individualized care plans, and collaboration with an interdisciplinary team to ensure timely access to services and safe transitions.

Qualifications

• RN licensure in any US state (unrestricted).

Responsibilities

• Coordinate comprehensive case management across inpatient, outpatient, and home-based settings.
• Oversee Home Healthcare services for eligible Veterans, including assessment and communication with providers.
• Coordinate outpatient Annual Examinations and comprehensive assessments of medical, functional, psychosocial needs.
• Develop, implement, monitor, and update individualized care plans.
• Coordinate referrals with VA programs, community resources, and other services.
• Facilitate communication among Veterans, families, providers, and the care team.
• Monitor ongoing caseload and ensure timely follow-up.
• Educate Veterans and caregivers about available services and care plans.
• Document assessments, interventions and outcomes in the EHR.
• Participate in interdisciplinary meetings and quality-improvement activities.
• Assist with process improvement to enhance Veteran outcomes and access.

Skills

Case management

Care coordination

Interdisciplinary teamwork

Communication

Education

RN licensure (unrestricted)

Job description

Veterans Health Administration in Long Beach, CA, seeks a Registered Nurse- Spinal Cord Injury/Disease Integrated Case Manager to coordinate comprehensive case management for Veterans across inpatient, outpatient, and home-based settings.

The role emphasizes coordination of Home Healthcare, outpatient Annual Examinations, development of individualized care plans, and collaboration with an interdisciplinary team to ensure timely access to services and safe transitions.