Registered Nurse- Community Care Coordinator

University of Minnesota School of Nursing; Minneapolis (MN); On-site; USD 85,000 - 110,000; Full time

Job summary

University of Minnesota School of Nursing seeks a Community Care Coordinator (RN) to lead care coordination and care management for veterans, including clinical triage of moderate and complex cases and authorized community care.

The CCC RN will demonstrate leadership and innovative approaches in this multifaceted environment, coordinating with VA and community providers to ensure safe, effective transitions and high-quality outcomes.

Qualifications

• English proficiency is required by VA guidelines.
• Candidate must maintain basic written and spoken English.
• Graduate nursing education must be from an approved program (ACEN/CCNE).
• Licensure via state board after bridge programs may be required.
• Foreign nursing graduates must show current unrestricted registration.
• BLS certification is required or obtainable on hire.
• Preferred experience: 3–5 years RN in care coordination, case management, or transitions of care.

Responsibilities

• Review referrals and create care plans for veterans under IVC guidance.
• Coordinate planned and unplanned care with community providers.
• Act as liaison between VA teams and non-VA facilities.
• Provide timely follow-up and patient education for safe transitions.
• Manage large caseload while meeting quality and documentation standards.

Skills

care coordination

leadership

clinical knowledge

communication

case management

Education

RN license (state)

Nursing degree (ADN/ Diploma or BSN)

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.