Registered Nurse- Community Care Coordinator

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

Job summary

Veterans Health Administration, Department of Veterans Affairs is seeking a Community Care Coordinator (RN) to manage care coordination for veterans with complex needs. You will triage, coordinate, and monitor community-based treatments and transitions of care in a fast-paced environment.

The role emphasizes leadership, collaboration with VA and non-VA providers, and ensuring high-quality, safe care with timely follow-ups and education for veterans and their families.

Qualifications

• RN with valid US state license and graduation from an approved nursing program.
• Accreditation by ACEN or CCNE for the nursing program.
• Foreign education requires degree equivalency validation when applicable.
• Active license in the United States to practice nursing.
• 3–5 years of RN experience in care coordination or related areas preferred.

Responsibilities

• Review referrals and develop care plans for veterans in community care.
• Coordinate planned and unplanned care with VA and community providers.
• Communicate with internal and external customers respectfully and timely.
• Lead and participate in a collaborative team approach for complex cases.
• Ensure patient education and safe transitions of care.

Skills

Care coordination

Leadership

Communication

Case management

Multidisciplinary collaboration

Education

RN license (state)

Approved nursing program (ACEN/CCNE)

Foreign nursing education evaluation

Bridge program option for master's-level study

BSN preferred or higher

Job description

Summary

The Community Care Coordinator (CCC) is a registered nurse (RN) responsible for care coordination and care management for veterans with clinical triage of moderate and complex - receiving authorized community care. The CCC RN is expected to demonstrate leadership - and innovative approaches in providing care coordination in this complex environment.

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
• Preferred Experience: 3-5 years of recent RN experience in care coordination - case management - population health - community care - primary care - ambulatory care - chronic disease management - or transitions of care
• Experience coordinating care for complex patients with multiple chronic conditions - behavioral health needs - and social determinants of health concerns
• Demonstrated experience developing and implementing individualized care plans - including assessment - care coordination interventions - monitoring outcomes - and care transitions
• Knowledge of evidence-based guidelines - chronic disease management - motivational interviewing - and patient education
• Demonstrated ability to manage a large caseload while meeting quality - timeliness - and documentation standards
• 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/13089506
• 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
• Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• Physical Requirements: You will be asked to participate in a pre-employment examination or evaluation as part of the pre-employment process for this position
• Questions about physical demands or environmental factors may be addressed at the time of examination.

Duties

• The CCC RN utilizes their clinical knowledge and expertise to review referrals and create a care plan to provide care coordination for both pre authorized and emergent episodes of care - following Integrated Veteran Care (IVC) guidance
• Major duties include - but are not limited to: Communicates and interacts appropriately and courteously with internal and external customers
• Triages and applies a collaborative team approach in identifying - analyzing - and resolving patient care problems
• Flexible - adaptable - and versatile
• displays the ability to adapt and overcome challenges in a fast paced environment
• Maintains confidentiality of patient/employee information electronically - verbally - and written
• Coordinates planned and unplanned care for veterans that is safe - effective - equitable and efficient in collaboration with selected community providers
• The CCC should have a strong clinical knowledge of common medical conditions requiring follow up after a surgery - procedures and hospitalization
• Emphasis on a collaborative process that assesses - advocates - plans - implements - coordinates - monitors and evaluates health care options and services to meet the individual patient's needs
• The role of the CCC is to act as a liaison between a Veteran's assigned VA PACT or CC-PCP team - MPLS VA HCS providers and clinics - and non-VA facilities where a Veteran is hospitalized or treated
• The CCC ensures a smooth transition of services through specific nursing interventions and thorough care coordination efforts
• Provides timely follow-up by addressing phone messages - faxes and alerts accordingly
• Assists with calling - sending letters - or emailing communication to Veterans regarding plan of care
• Ensures and provides education relevant to the effective progression of care and the appropriate level of care for safe patient transition
• Serves as case manager for veterans with Community Care-Primary Care
• Maintains communication and track authorizations to prevent a lapse in care - anticipates care coordination needs
• BLS certification is required for this position and can be obtained upon hire
• Facilitation of referrals and recommendations to support ongoing veteran needs
• Demonstrates professional communication - conduct and leadership skills - including willingness to accept increasing levels of accountability
• RN should be comfortable with decision-making responsibilities
• 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 - 7:30am-4:00pm Telework: ADHOC-May be authorized (Employee who Telework on an occasional - episodic - or short-term - and have completed required telework training and telework agreement)
• Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized The VA Midwest Health Care Network advocates for a Whole Health System of care in each of the Medical Centers
• This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest
• As an employee operating in a Whole Health System of care - you will operate in a model with three core elements - seeking to create a personalized health plan for each Veteran
• This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community
• This aligns with the Veterans Health Administration (VHA) Mission Statement to Honor America's Veterans by providing exceptional health care that improves their health and well-being.