Registered Nurse - Case Manager/Care Coordinator

U.S. Department of Veterans Affairs; Lexington (KY); Remote; USD 71,000 - 138,000; Full time

Benefits offered by this job

Telework available

Federal benefits package

Job summary

The U.S. Department of Veterans Affairs seeks a Registered Nurse – Case Manager/Care Coordinator to provide clinical oversight, care coordination, and medication management for Veterans in contracted community nursing homes.

You will ensure safe transitions, timely communication, and Veteran-centered care across VA and community settings. Join an interdisciplinary team, support quality-improvement initiatives, and participate in flexible schedules with ad-hoc telework options.

Qualifications

• A transcript must be submitted with your application.
• Education recognized by the U.S. Department of Education may be used to qualify for Federal employment.
• One full and unrestricted RN license from any US State or territory is required.
• If using foreign education, submit a Certificate of Foreign Equivalency with your transcript.

Responsibilities

• Provide clinical oversight, case management, and care coordination for Veterans in contracted community nursing home facilities.
• Collaborate with the Social Worker, Program Coordinator, PACT, and interdisciplinary team to deliver Veteran-centered care.
• Assess, plan, implement, and evaluate care based on patient age, health status, and preferences.
• Review medications during facility visits; conduct reconciliation and monitor outcomes.
• Document encounters in CPRS and coordinate admissions, transfers, and discharges.
• Maintain program rosters, reports, and tracking tools; support transitions of care.
• Coordinate with Prosthetics, hospice, and care-team for equipment and specialist input.
• Participate in quality-improvement, performance-monitoring, and customer-service initiatives.

Education

RN license

Job description

Registered Nurse - Case Manager/Care Coordinator

• Department: Department of Veterans Affairs

The Community Nursing Home Program RN provides clinical oversight, case management, care coordination, and ongoing communication for Veterans receiving care in contracted community nursing home facilities. The RN is responsible for promoting continuity of care, access to services, appropriate utilization, Veteran safety, and effective transitions across VA and community care settings.

Key Responsibilities

The RN works under the direction of the designated supervisor and collaborates with the Social Worker, Program Coordinator, PACT, nursing home staff, Prosthetics, Care in the Community, Hospice, and other members of the interdisciplinary team to provide coordinated, Veteran-centered care.

The RN applies the nursing process by assessing, planning, implementing, and evaluating care based on the Veteran's age, health status, functional needs, psychosocial circumstances, values, culture, and preferences. Core Responsibilities Visit assigned contracted nursing home facilities every 60 days, alternating visits with the Program Coordinator. Assess enrolled Veterans during facility visits and document each encounter in CPRS.

Review the Veteran's medication regimen during facility visits and care coordination activities, including medication reconciliation, indication, effectiveness, adherence, potential adverse effects, duplications, interactions, and clinical changes that may warrant follow-up.

Compare medication information across available VA, nursing home, hospital, specialty, and hospice records, and communicate discrepancies or concerns to the appropriate provider, facility staff, PACT, pharmacist, and other members of the care team. Monitor for medication-related risks, including falls, sedation, hypotension, hypoglycemia, bleeding, adverse drug reactions, and other concerns relevant to the Veteran's condition and care setting.

Ensure medication changes associated with admissions, hospitalizations, returns to the facility, transfers, leaves of absence, and discharges are communicated and documented appropriately. Complete and coordinate required depression screenings and updates to VA contact information at admission and annually. Maintain an accurate and current roster of Veterans enrolled in the program and report discharges to the appropriate team members.

Document facility-status changes-including falls, hospital transfers, returns to the facility, and leaves of absence-in CPRS and notify program staff. Report falls promptly to the Program Coordinator and obtain all relevant clinical and incident details from the nursing home. Coordinate Care in the Community requests by obtaining required clinical documentation, forwarding information to the appropriate team, and documenting requests in CPRS.

Coordinate requests for specialty equipment with nursing home staff, the Veteran's care team, and Prosthetics. Support the hospice contract approval process by coordinating physician reviews, tracking determinations, updating the hospice spreadsheet, and communicating outcomes to appropriate staff. Maintain accurate program records, shared calendars, rosters, spreadsheets, and tracking tools.

Coordinate routinely with the Social Worker, Program Coordinator, PACT, nursing home staff, and other relevant clinical and administrative personnel to address medical, functional, psychosocial, caregiver, and care-transition needs. Identify psychosocial concerns and refer Veterans and families to Social Work for assistance with caregiver support, advance care planning, benefits, community resources, discharge planning, and other supportive services.

Provide or coordinate patient and family education, support Veteran self-management when appropriate, and promote active participation in care planning. Administer medications and perform nursing procedures in accordance with established policies, procedures, and clinical guidelines. Collaborate with the interdisciplinary team to influence care outcomes and support safe, timely, and appropriate transitions of care.

Participate in program-level quality-improvement initiatives, performance-monitoring activities, customer-service programs, and other strategies supporting efficient and effective patient management.

Pay Scale: NF23 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: M-F 0730-1600 or 0800-1630 Telework: Available (Ad-hoc) 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.

Requirements & Education

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 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 with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.

Which agency is hiring for this position?

This position is with Veterans Health Administration, Department of Veterans Affairs.

What is the salary for this position?

The posted pay range is $71176 – $137765/yr.

Is this position remote or telework eligible?

This position is eligible for telework.

What security clearance is required?

This position requires a Other security clearance.

What is the application deadline?

Applications close on 2026-11-16.

Who is eligible to apply?

This position is open under the 'Fed Internal Search' hiring path.