Registered Nurse - Community Care Coordinator

Diversity Group; Wilkes-Barre (Luzerne County); On-site; USD 90,000 - 110,000; Full time

Benefits offered by this job

Paid Time Off

Federal health/vision/dental insurance

Traditional federal pension and 401K

Job summary

Diversity Group is seeking an experienced Community Care Coordinator RN to oversee triage and coordination of Veteran care in a structured environment. The role emphasizes nursing process across VA and community settings with a focus on timely, quality outcomes.

The position requires an RN license and nursing program completion, with preferred BSN (1 year experience) or MSN for advanced leadership, and adherence to VHA guidelines and equity-focused care.

Qualifications

• English language proficiency is required for direct patient care.
• Current RN license or eligibility for licensure in the US.
• Graduate of an approved Nursing program with accrediting body.
• Foreign education licensure validation may be required for full licensure.

Responsibilities

• Assess, plan, implement and evaluate Veteran care.
• Coordinate care across VA and community services.
• Triaging and directing timely, coordinated care for Veterans.
• Collaborate with interdisciplinary team to meet care goals.
• Maintain documentation per VHA standards and guidelines.

Skills

English Proficiency

Education

Associate Degree in Nursing (ADN) or Diploma in Nursing

Bachelor of Science in Nursing (BSN) with 1 year experience

Master’s degree in Nursing (MSN)

Job description

Summary

The Community Care (CC) Coordinator Registered Nurse (RN) is responsible for executing a streamlined approach to receiving - triaging - and directing timely - coordinated care. The nurse demonstrates proficient practice and decision-making - deliberate planning - and critical thinking skills.

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/13079610
• 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: VA Community Care - Case Management or Home Health experience
• 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 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 evaluation.

Duties

• The Community Care (CC) Coordinator Registered Nurse (RN) is responsible and accountable for all elements of the nursing process when providing and/or supervising direct patient care
• Assesses - plans - implements - and evaluates the effectiveness of the Veteran's care
• Serves to support delivery of high quality - timely care to the Veteran receiving services in the community
• Assumes responsibility for the coordination of care focused on patient education - self-management - and customer satisfaction throughout the continuum of care
• Follows procedures per established policies and guidelines
• Influences care outcomes by collaborating with members of the interdisciplinary team
• Core elements of performance include knowledge and active participation in the unit/program level quality improvement process and initiatives as well as customer service programs
• Executes position responsibilities that demonstrate leadership - experience - and creative approaches to management of complex client care
• Additional duties include - but are not limited to: Possesses 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
• Uses 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 ...
• Serves as a liaison to both internal and community providers and is responsible for managing the care of the Veteran throughout the consult process
• Supports 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
• Works 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
• Collaborates with members of the interdisciplinary team both within the Veterans Affairs (VA) and in the community
• Complies with VA-mandated processes and use of health information solutions that serve to assess - document - exchange - and track care coordination information
• Utilizes delegation of authority - if applicable - to function at their highest level of role performance and align high-quality care with key performance indicators to ensure practice standards meet patient care needs
• Evaluates outcomes of evidence-based decisions and practice changes for individuals - groups - and populations
• Responsible for the documented outcomes at the program or service level
• This position may require long periods of sitting through meetings and/or at the computer
• Additional duties as assigned
• 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: 8:00am - 4:30pm - Monday - Friday Telework: Not Available Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized