Registered Nurse- Spinal Cord Injury/Disease (SCI/D) Integrated Case Manager

Veterans Health Administration

Long Beach (CA)

On-site

USD 114,000 - 195,000

Full time

5 days ago

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Job summary

Veterans Health Administration in Long Beach, CA, seeks a Registered Nurse- Spinal Cord Injury/Disease Integrated Case Manager to coordinate comprehensive case management for Veterans across inpatient, outpatient, and home-based settings.

The role emphasizes coordination of Home Healthcare, outpatient Annual Examinations, development of individualized care plans, and collaboration with an interdisciplinary team to ensure timely access to services and safe transitions.

Qualifications

RN licensure in any US state (unrestricted).

Responsibilities

Coordinate comprehensive case management across inpatient, outpatient, and home-based settings.
Oversee Home Healthcare services for eligible Veterans, including assessment and communication with providers.
Coordinate outpatient Annual Examinations and comprehensive assessments of medical, functional, psychosocial needs.
Develop, implement, monitor, and update individualized care plans.
Coordinate referrals with VA programs, community resources, and other services.
Facilitate communication among Veterans, families, providers, and the care team.
Monitor ongoing caseload and ensure timely follow-up.
Educate Veterans and caregivers about available services and care plans.
Document assessments, interventions and outcomes in the EHR.
Participate in interdisciplinary meetings and quality-improvement activities.
Assist with process improvement to enhance Veteran outcomes and access.

Skills

Case management

Care coordination

Interdisciplinary teamwork

Communication

Education

RN licensure (unrestricted)

Job description

Registered Nurse- Spinal Cord Injury/Disease (SCI/D) Integrated Case Manager

Department: Department of Veterans Affairs

The Registered Nurse Case Manager reports to the Chief of Spinal Cord Injury Service.

Key Responsibilities

The Case Manager will provide comprehensive case management and care coordination services to Veterans across inpatient, outpatient, and home-based settings. The position will have dual responsibilities, including coordination and oversight of Home Healthcare services, outpatient Annual Examinations, and other case management activities as assigned.

The Case Manager will work collaboratively with Veterans, families/caregivers, providers, social workers, nursing staff, and other interdisciplinary team members to promote continuity of care, timely access to services, and safe transitions across healthcare settings. Coordinate and manage Home Healthcare services for eligible Veterans, including assessment of needs, coordination of services, follow-up, and communication with healthcare providers.

Conduct and/or coordinate outpatient Annual Examinations for Veterans, ensuring required evaluations and follow-up needs are addressed. Perform comprehensive assessments of Veteran needs, including medical, functional, psychosocial, environmental, and support-system needs. Develop, implement, monitor, and update individualized care plans. Coordinate referrals and services with VA programs, community resources, specialty services, and other healthcare agencies.

Facilitate communication among Veterans, caregivers, providers, and interdisciplinary team members. Identify barriers to care, discharge, access to services, and continuity of care and assist in developing solutions. Monitor Veterans requiring ongoing case management and ensure appropriate follow-up. Provide education to Veterans and caregivers regarding available healthcare services, resources, and care plans.

Document assessments, interventions, coordination activities, and outcomes accurately and timely in the electronic health record. Participate in interdisciplinary team meetings, case conferences, huddles, and quality-improvement activities. Monitor program requirements, performance measures, and documentation standards. Assist with process improvement initiatives designed to improve Veteran outcomes, access, patient flow, and continuity 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: Monday through Friday, 7:0am to 3:30pm Compressed/Flexible: May be considered for highly qualified candidates.

Telework: Not available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not authorized Permanent Change of Station (PCS): Not authorized

Which agency is hiring for this position?

This position is with Veterans Health Administration, Department of Veterans Affairs.

What is the salary for this position?

The posted pay range is $114291 – $195498/yr.

What security clearance is required?

This position requires a Other security clearance.

What is the application deadline?

Applications close on 2026-10-16.

Who is eligible to apply?

This position is open under the 'Fed Internal Search' hiring path.