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

Inspire Health Alliance; Long Beach, Northern (CA, KY); Hybrid; USD 100,000 - 135,000; Full time

Benefits offered by this job

Total rewards package

Job summary

Department of Veterans Affairs is seeking a Registered Nurse Case Manager to coordinate comprehensive case management for Veterans across inpatient, outpatient, and home-based settings.

The role emphasizes collaboration with families, caregivers, and an interdisciplinary team to ensure timely access to services, safe transitions, and high-quality Veteran-centered care.

Qualifications

• English language proficiency required by law.
• Graduate of an accredited nursing program with RN licensure.
• State RN license required on appointment (GNT option possible).
• Foreign nursing grads must have full active unrestricted US registration.
• Experience in case management or home health care is preferred.

Responsibilities

• Provide comprehensive case management for Veterans across inpatient, outpatient, and home settings.
• Coordinate and oversee Home Healthcare services and Annual Examinations.
• Develop and update individualized care plans with multidisciplinary teams.
• Communicate with Veterans, families, and providers to ensure continuity of care.
• Document assessments, interventions, and outcomes in the EHR.
• Participate in team meetings and quality-improvement activities.

Skills

English proficiency

Clinical nursing

Care coordination

Interdisciplinary collaboration

Education

Associate Degree in Nursing (ADN)

Diploma in Nursing

Bachelor of Science in Nursing (BSN)

RN license

Tools

Electronic Health Records (EHR)

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