Registered Nurse - Community Care Coordinator

Veterans Health Administration, Department of Veterans Affairs; Milwaukee (WI); On-site; USD 80,000 - 100,000; Full time

Job summary

The Veterans Health Administration Community Care RN role focuses on coordinating care for Veterans receiving services in the community, emphasizing patient education, self-management, and satisfaction across the continuum of care.

You will work within VA guidelines, collaborate with internal and community providers, and support timely access to care with a focus on quality. A state nursing license and ACEN/CCNE‑accredited education are preferred.

Qualifications

• English language proficiency required.
• Graduate of an ACEN- or CCNE-accredited nursing program.
• Current, full, active nursing license in a U.S. state or territory.
• Experience in care coordination or case management preferred.
• Knowledge of VA patient care regulations and standards.

Responsibilities

• Coordinate complex care for Veterans in the community.
• Prioritize and triage consults based on patient complexity.
• Liaise with internal and community providers to manage care.
• Support timely access to high-quality care and education.
• Ensure compliance with VA policies and documentation requirements.

Skills

Nursing

Care coordination

Patient education

Communication

Case management

Education

BSN

ADN / Diploma in Nursing

State nursing license

Tools

Electronic Health Records

Job description

Summary

The Community Care RN supports delivery of high quality - timely care to the Veteran receiving services in the community. They assume responsibility for the coordination of care focused on patient education - self-management - and customer satisfaction 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/13088529
• 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: 2-3 years clinical experience 1+ years in a case management or care coordination role Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• Physical Requirements: This position includes a level of physicality normally associated with duties performed by nurses such as direct patient care - and potentially long periods of walking - standing - sitting - moderate lifting - repeated bending - or kneeling
• Examples may include but are not limited to: - Significant amounts of time standing assisting assigned patients - Utilization of safe patient handling and mobility protocols

Duties

• Community Care is a rapidly changing and fast paced environment
• The work is in an office setting and is consult driven
• The Community Care RN is responsible for the coordination of complex care for our Veteran's eligible for Community Care
• Coordination of the Veteran's care requires the RN to prioritize and triage consults based on Veteran's complexity
• The Community Care RN is an integral part of the Community Care team that is comprised of MSA's - PSA's - other RN's
• Duties include - but are not limited to: Possess intimate knowledge of the internal referral care process - clinical review criteria - utilization management standards - clinical documentation requirements - community care regulations - and Veterans Health Administration (VHA) standards and guidelines
• Use nursing knowledge and systems theory to assess - organize - facilitate - and guide Veterans through their full range of care options including internal/direct care in Veterans Affairs (VA) and care in the community
• Serve as a liaison to both internal and community providers and is responsible for managing the care of the Veteran throughout the consult process
• Support the medical center's mission to improve timely access to care - ensure Veterans who want to receive care in the community are referred and scheduled into the community - and support the delivery of high quality - timely care to the Veteran receiving community services
• Work collaboratively within the Office of Integrated Veteran Care (IVC) to triage Request for Services (RFS) to coordinate care processes defined by the IVC Field Guidebook to include developing a care coordination plan - reviewing medical documentation from community providers - communication of care coordination needs - and supporting the Veteran through the completion of the episode of care
• 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: 0730 - 1600 or 0800 - 1630 - Monday - Friday Telework: Not Available Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized