Registered Nurse - Community Nursing Home Care Coordinator

Quick Facts

• Role: Registered Nurse (Community Nursing Home Care Coordinator)

Description

Assess, plan, implement, and evaluate age-specific nursing care and outcomes to ensure timely, appropriate services. Coordinate care across inpatient and outpatient settings, with a focus on patient/family education, self-management, and customer satisfaction throughout the continuum of care. Collaborate with an interdisciplinary team to improve care outcomes and ensure appropriate service delivery in VA and community programs.

Responsibilities

• Provide patient management, care coordination, and discharge/disposition planning for inpatient and outpatient settings.

• Assist veterans, families, and caregivers in selecting appropriate options and community services for complex health needs.

• Coordinate care with multiple providers and ensure service interface continuity within VA and CNH programs.

• Perform clinical nursing review of medical records from non-VA hospitalizations to determine clinical stability for payment and potential transfer to a VA facility.

• Use utilization management knowledge and understand clinical documentation requirements and compliance guidelines.

• Maximize third-party payments and participate in patient care performance improvement activities.

• Develop and coordinate seamless transitions between inpatient and outpatient processes with a focus on discharge planning.

• Review and support referrals to CNH facilities to maintain continuity of qualified comprehensive care.

• Participate in discharge planning assessments and implement community health services (e.g., skilled nursing, hospice, adult day health, respite, and related activities).

• Conduct follow-up and oversight visits after CNH admission to ensure adequate and safe care under VA contract.

• Advocate for holistic care through education and implement an educational plan meeting patient care needs.

Benefits

• Competitive salary with regular increases and potential performance awards

• Paid Time Off: 50 days/year (annual leave, sick leave, and federal holidays)

• Retirement: traditional federal pension and federal 401K with up to 5% employer contribution

• Insurance: federal health/vision/dental/term life/long-term care options

• Licensure: requirement for 1 full and unrestricted license from any U.S. state or territory

• Work schedule: intermittent part-time, Monday–Friday, 7:30am–4:00pm (subject to facility needs)

• Relocation/Recruitment incentives: not authorized; PCS not authorized

• Not telework; not virtual