Registered Nurse (Care Manager)- Home Based Primary Care

Veterans Health Administration, Department of Veterans Affairs; Spokane (WA); On-site; USD 80,000 - 110,000; Full time

Benefits offered by this job

Paid Time Off (PTO) 50 days/year

Federal pension & 401K match

Federal health/vision/dental insurance

Job summary

Veterans Health Administration, Department of Veterans Affairs, seeks an RN Case Manager to deliver comprehensive, patient-centered care to Veterans at home through the HBPC program. The role focuses on complex healthcare needs, promoting independence, and coordinating multidisciplinary care with families and providers.

Preferred qualifications include BSN and diverse home health experience. The position emphasizes care planning, medication management, and telehealth as appropriate within a

Qualifications

• English language proficiency is required.
• Graduate of a nursing program approved by ACEN/CCNE.
• An ADN or Diploma in Nursing is acceptable with appropriate licensure.
• BSN preferred; may require bridging program for licensure.
• Current, full, active RN license in a US state or territory.

Responsibilities

• Provide direct Veteran care and care coordination within the HBPC program.
• Perform case management, assessment, triage, Veteran education, and care planning.
• Deliver technically competent home-based nursing care and health promotion.
• Collaborate with an interdisciplinary team to optimize Veteran outcomes.

Skills

English language proficiency

Education

ADN or Diploma in Nursing

BSN

State RN license

Accredited nursing program (ACEN/CCNE)

Job description

Summary

The RN Case Manager provides comprehensive - patient-centered nursing care to Veterans in the comfort of their homes through the Home Based Primary Care (HBPC) program. this position focuses on supporting Veterans with complex healthcare needs by promoting independence - improving quality of life - and ensuring coordinated - comprehensive care. The RN works collaboratively with an interdisciplinary team to support Veterans and their families throughout the continuum of 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: https://apply.usastaffing.gov/ViewQuestionnaire/13098030
• 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: Registered nurse experience in home health - home based primary care - community or public health nursing - case management - or ambulatory primary care
• Experience caring for older adults and Veterans with multiple chronic conditions - dementia - and functional decline - including palliative and end-of-life care
• Care management of a defined caseload - including care planning - care coordination - and follow-up after emergency department visits and hospital discharges
• Medication reconciliation and medication management for patients on complex regimens
• Phlebotomy and point-of-care testing
• injections and immunizations
• Wound care - including pressure injury assessment and staging
• indwelling and suprapubic catheter care
• ostomy care
• Telephone triage and virtual care - including VA Video Connect or similar telehealth
• Independent practice in the community: working alone - managing a daily visit route - and using sound judgment in home settings
• Interdisciplinary team practice with providers - social work - rehabilitation - nutrition - pharmacy - and psychology
• Valid driver's license and comfort driving rural roads and in winter conditions
• BSN preferred
• Certification valued: Certified Case Manager (CCM) - Gerontological Nursing (GERO-BC) - Hospice and Palliative (CHPN) - Home Health - or wound care
• Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• Physical Requirements: Heavy lifting (45 pounds and over) - Moderate carrying (15-44 pounds) - Pushing (5 hours) - Reaching above shoulder - Use of fingers - Both hands required - Walking (2 hours) - Standing (5 hours) - Kneeling (5 hours) - Repeated bending (5 hours) - Both legs required - Operation of crane - truck - tractor - or motor vehicle - Ability for rapid mental and muscular coordination simultaneously - Near vision correctable at 13'' to 16'' to Jaeger 1 to 4 - Far vision correctable in one eye to 20/20 and to 20/40 in the other - Specific visual requirement (peripheral vision) - Ability to distinguish basic colors - Hearing (aid permitted).

Duties

• Duties include but are not limited to: Responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimal outpatient care
• Provide direct Veteran care and care coordination - as it pertains - to Veterans and their care within the HBPC Program
• Responsible for case management - assessment - triage - Veteran education - resource coordination - medication and treatment coordination - and care planning
• Plan and deliver technically competent care in the home of Veterans with complex needs - including health promotion - health prevention - geriatric care - primary care - and palliative care
• Utilize interventions - which maximize health capabilities and reduces unnecessary urgent care and emergency room visits - per Veteran's goals of care
• Make home visits to Veterans in the program
• Seek guidance on how to improve care provided to patients and families
• Delegate elements of care to the appropriate individual based upon assessed needs - condition - and safety of patient
• Bring HBPC principles and theory with limited application of critical thinking skills
• Administer medications and procedures per established policies and guidelines
• Influence care outcomes by collaborating with members of the interdisciplinary team
• 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 8:00am-4:30pm Compressed/Flexible: May be authorized Telework: Not Available Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized