Registered Nurse (Community Care Coordinator)

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. Assumes responsibility for the coordination of care focused on patient education, self-management, and customer satisfaction throughout the continuum of care.

Duties include but not limited to :

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.

Community Care (CC) Coordinator Registered Nurse (RN) is responsible for executing a streamlined approach to receiving, triaging, and directing timely, coordinated care. The nurse demonstrates proficient practice and decision-making, deliberate planning, and critical thinking skills. The CC Coordinator 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. The CC Coordinator 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. The CC Coordinator serves as a liaison to both internal and community providers and is responsible for managing the care of the Veteran throughout the consult process. The CC Coordinator 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.

The CC Coordinator will 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. The CC Coordinator will influence care outcomes by collaborating with members of the interdisciplinary team both within the Veterans Affairs (VA) and in the community. The CC Coordinator will comply with VA-mandated processes and use of health information solutions that serve to assess, document, exchange, and track care coordination information. The CC Coordinator will 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. Fosters a safe and supportive environment conducive to the professional development of healthcare professionals. 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 evidence-based-practice.

Work Schedule : 07 : 00 - 15 : 30 or depending on service needs