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

Veterans Health Administration, Department of Veterans Affairs; Long Beach (CA); On-site; USD 90,000 - 110,000; Full time

Benefits offered by this job

Paid Time Off

Federal benefits

Job summary

Veterans Health Administration, Department of Veterans Affairs, is seeking a Registered Nurse Case Manager to coordinate nationwide Veteran care across inpatient, outpatient, and home settings. The role supports home health services and annual examinations while maintaining high-quality, veteran-centered care.

Flexibility to work within interdisciplinary teams is essential, with emphasis on timely access to services and safe care transitions.

Qualifications

• Graduate of an approved nursing program with current U.S. licensure.
• Ability to obtain state nursing licensure and work in direct patient care.
• Experience in case management or coordinating home health services is preferred.
• Knowledge of veterans' healthcare needs and interdisciplinary collaboration.

Responsibilities

• Provide comprehensive case management and care coordination across inpatient, outpatient, and home-based settings.
• Coordinate and oversee Home Healthcare services for eligible Veterans.
• Conduct outpatient Annual Examinations and address follow-up needs.
• Develop, implement, and monitor individualized care plans.
• Collaborate with Veterans, families, providers, social workers, and nursing staff to ensure continuity of care.
• Document assessments, interventions, and outcomes in the EHR in a timely manner.
• Participate in team meetings, case conferences, and quality improvement activities.

Skills

English proficiency

Nursing licensure

Case management

Interdisciplinary collaboration

Education

ADN or Diploma in Nursing

BSN with 1 year experience

MSN with no additional experience

Job description

Summary

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

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/13088072
• 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:The ideal candidate should be flexible - self-directed - organized - clinically strong - customer-service oriented - and comfortable working across multiple care settings
• Because this is a dual-responsibility position - the individual must be able to transition effectively between home healthcare coordination - outpatient Annual Examinations - case management - and emerging program needs while maintaining high-quality Veteran-centered care
• Case Management (CCM) board certification preferred
• MSN preferred.2-3 years in case management in SCI/D or rehabilitation settings preferred
• Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• Physical Requirements: Heavy lifting (45 lbs and over)
• Heavy carrying (45 lbs and over)
• Straight pulling and pushing
• reaching above shoulder
• use of fingers
• both hands required
• walking and standing up to 8 hours
• repeated bending
• Ability for rapid mental and muscular coordination simultaneously
• hearing aid permitted.

Duties

• 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