Registered Nurse (RN) - Community Care (CC) Coordinator

Veterans Health Administration, Department of Veterans Affairs; Town of Tomah (WI); On-site; USD 80,000 - 110,000; Full time

Job summary

The Registered Nurse (RN) - Community Care (CC) Coordinator is responsible for delivering and supervising nursing process across community care, triaging requests, and directing timely, coordinated care for Veterans.

This role requires deep knowledge of VA community care regulations, referral workflows, utilization management, and documentation standards, with collaboration across VA service lines and community providers.

Qualifications

• English language proficiency required for direct patient care per VA guidelines.
• Graduate of a nursing program approved and ACEN/CCNE accredited.
• State license upon appointment; temporary-to-permanent after bridge completion.
• Foreign education requires degree equivalency validation if applicable.
• Refer to VA Qualification Standards; GNT exception provisions may apply.

Responsibilities

• Provide CC coordination and nursing process across VA and community settings.
• Triage referrals, assess patient needs, and facilitate timely access to care.
• Serve as liaison between Veterans, VA staff, and community providers.
• Develop and implement care coordination plans and document accordingly.
• Support evidence-based practice and participate in interdisciplinary teams.
• Maintain compliance with community care regulations and documentation standards.

Skills

English language proficiency

Education

Bachelor of Science in Nursing (BSN)

Associate Degree in Nursing (ADN) or Diploma in Nursing

Registered Nurse license (unrestricted)

Job description

Summary

Registered Nurse (RN) - Community Care (CC) Coordinator is responsible for executing a streamlined approach to receiving - triaging - and directing timely - coordinated care. The incumbent of this position 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.

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/13094300
• 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: BSN or higher education level preferred
• 2-3 years of professional RN case management experience is highly preferred
• Previous Outpatient or Community Care RN experience is preferred
• Strong - demonstrated proficiency with the Microsoft 365 Suite
• 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

• THIS IS NOT A REMOTE POSITION
• The Registered Nurse (RN) - Community Care (CC) Coordinator is responsible and accountable for all elements of the nursing process when providing and/or supervising direct patient care
• The person in this role assesses - plans - implements - and evaluates the effectiveness of the Veteran's care
• In addition - this incumbent will serve to support delivery of high quality - timely care to the Veteran receiving services in the community
• When appropriate - CC Coordinators are expected to assume the responsibility of a Care Coordination and Integrated Case Management (CCICM) Lead Coordinator serving as the primary point of contact for Veterans who require moderate to complex care coordination - oversee - and facilitate integrated care across VA service lines - healthcare settings - and treatment episodes ensuring seamless and comprehensive care is provided
• The RN - CC Coordinator is also responsible for the following duties: Using 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
• Serving as a liaison to both internal and community providers and managing the care of the Veteran throughout the consult process
• Supporting the medical center's mission to improve timely access to care (ensuring Veterans who want to receive care in the community are referred and scheduled into the community)
• Supporting the delivery of high quality - timely care to the Veteran receiving community services
• Working 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 (i.e
• - including developing a care coordination plan - reviewing medical documentation from community providers - communication of care coordination needs - supporting the Veteran through the completion of the episode of care)
• Influencing care outcomes by collaborating with members of the interdisciplinary team - both within the Veterans Affairs (VA) and in the community
• Using delegation of authority - if applicable - to function at their highest level of role performance and align high-quality care with key performance indicators - ensuring practice standards meet patient care needs
• Fostering a safe and supportive environment conducive to the professional development of healthcare professionals
• Contributing professional nursing perspective in discussions with the interdisciplinary team
• Partnering with others to effect change and produce optimal outcomes
• Supporting colleagues through knowledge sharing to provide safe - quality nursing care
• Sharing educational findings - experiences - and ideas with peers
• Questioning clinical practices for the purpose of providing evidence-based care
• Participates in activities and strategies to sustain evidence-based-practice
• Other 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: Up to 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: Full-time (1 FTE) - (Days/PMs) 0800 - 1630 - Tour of Duty (TOD) may change depending on facility needs
• Telework: Ad-hoc - as determined by the agency policy
• Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not Authorized
• Permanent Change of Station (PCS): Not Authorized.