Registered Nurse- Care in the Community Care Coordinator

Department of Veterans Affairs

The Care in the Community (CITC) Care Coordinator Registered Nurse is responsible 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.

• CTVHCS is in the process of making a cultural change, shifting from a disease-focused approach to a health and wellbeing approach, in order to implement the Whole Health System of Care. This is a VA-wide initiative to provide a comprehensive and systematic approach to improve healthcare delivery at all stages of Veteran care. This entails moving from an episodic, "siloed" approach to an interdisciplinary, holistic approach, emphasizing self-care in the larger context of well-being. All staff in this facility will be part of this process, shifting the focus from the question, "What's the matter with you?" to the question, "What matters to you, and how can we help you live your best life?" This strategy also involves integrating a full range of conventional approaches with Complementary and Integrative Health (CIH) approaches in order to optimize lifelong health and well-being, as defined by the Veteran, rather than narrowly focusing on disease management. The Care in the Community (CITC) Care Coordinator Registered Nurse duties and responsibilities include, but are not limited to the following: 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. Supports the medical center's mission to improve timely access to care, ensure Veterans who want to receive care in the community are referred and scheduled into the community, and support the delivery of high quality, timely care to the Veteran receiving community services. Works 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. Complies with VA mandated processes and use of health information solutions that serve to assess, document, exchange, and track care coordination information. Utilize delegation of authority, if applicable, to function at their highest level of role performance and align high quality care with key performance indicators to ensure practice standards meet patient care needs. Contributes professional nursing perspective in discussions with the interdisciplinary team. 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. Questions clinical practices for the purpose of providing evidence-based care. Participates in activities and strategies to sustain an evidence-based-practice culture. 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, 7:30am - 4:00pm or 8:00am - 4:30pm Telework: Not available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

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