Registered Nurse (Community Care Coordinator)

Summary

Registered Nurse Community Care Coordinator 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.

DUTIES MAY INCLUDE HOWEVER ARE NOT LIMITED TO THE FOLLOWING:

• 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.
• Responsible for executing a streamlined approach to receiving, triaging, and directing timely, coordinated care.
• Demonstrates proficient practice and decision-making, deliberate planning, and critical thinking skills.
• 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 care in the community.
• Serves as a liaison to both internal and community providers and is responsible for managing the care of the Veteran throughout the consult process.
• Work 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.
• Influence care outcomes by collaborating with members of the interdisciplinary team both within the Veterans Affairs (VA) and in the community.
• Comply with VA-mandated processes and use of health information solutions that serve to assess, document, exchange, and track care coordination information.
• Fosters a safe and supportive environment conducive to the professional development of healthcare professionals.
• Partners with others to effect change and produce optimal outcomes. Supports colleagues through knowledge sharing to provide safe, quality nursing care. Shares educational findings, experiences, and ideas with peers.
• work collaboratively to coordinate care for the Veteran hospitalized in community facilities to include reporting a community hospital presentation to the Emergency Care Reporting system (ECR) as needed and initiating care coordination in ECR.
• Applies clinical knowledge/judgment to lead staff involvement in planning, decision-making, and evaluating outcomes within the immediate practice setting.
• Serves as an advocate for patients, families, and caregivers, improving outcomes for the immediate practice setting.
• Serves as a resource for patients, caregivers, and staff to address and resolve ethical issues in the immediate practice setting.
• Respects the opinions, abilities, and contributions of others.
• Encourages individual growth and development.
• Effectively sets group goals and keeps self and team informed of the latest trends and developments.
• Participates in the advancement of the profession through mentoring, precepting, and/or teaching.
• Leads patient care improvement through monitoring, analyzing, and evaluating care outcomes in the immediate practice setting.

Preferred Experience: Registered Nurse with minimum of 3 years clinical experience. Experience in Primary Care and Sub-specialties such as Acute Care. Applicant understands various sub-specialties, can prioritize, and has critical thinking and customer service skills.

Location: can either be located onsite at Canandaigua or Bath VAMC location.

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 - Friday, 8:00am - 4:30pm
Virtual: This is not a virtual position.
Permanent Change of Station (PCS): Not Authorized.
PCS Appraised Value Offer (AVO): Not Authorized.

Requirements

Conditions of employment

• U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA.
• Selective Service Registration is required for males born after 12/31/1959.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Must pass pre-employment physical examination.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• You may be required to serve a probationary period.
• Complete all application requirements detailed in the "Required Documents" section of this announcement.

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.

Preferred Experience: Registered Nurse with minimum of 3 years clinical experience. Experience in Primary Care and Sub-specialties such as Acute Care. Applicant understands various sub-specialties, can prioritize, and has critical thinking and customer service skills.

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.

Physical Requirements: A pre-employment physical is a condition of employment for this position.

Pay: $71,948.00 - $126,196.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Flexible spending account
• Free parking
• Health insurance
• Health savings account
• Life insurance
• Paid sick time
• Paid time off
• Parental leave
• Referral program
• Retirement plan
• Vision insurance

People with a criminal record are encouraged to apply

Work Location: In person

Salary : $71,948 - $126,196