Community Nursing Home Coordinator-Registered Nurse

About the role

The Community Nursing Home (CNH) Coordinator Registered Nurse (RN) provides patient management - care coordination - and discharge/disposition planning for Community Nursing Home Veterans. Reviews and assists referrals to CNH facilities - performs follow-up and oversight visits after admission to the CNH to ensure adequate and safe care is being provided. Advocates for holistic care through education and provider interaction and implements an educational plan to meet the patient care needs.

Responsibilities

• Aid Veterans, family members, and caregivers with respect to the most appropriate options and services to meet their complex healthcare needs.
• Coordinate care focused on patient education - self-management - and customer satisfaction throughout the continuum of care.
• Assess, plan, implement, and evaluate care based on age-specific components.
• Evaluate, review medical records of patients who are hospitalized in non-VA hospitals to determine point of stability for payment purposes and potential for transfer to a VA facility.
• Maximize third-party payments for care and deliver quality patient care performance improvement activities.
• Develop and coordinate seamless transitions of patients throughout the inpatient and outpatient care process with a focus on discharge planning needs.
• Review and assist in patient referrals to CNH facilities to ensure continuity of qualified comprehensive care.
• Participate in discharge planning assessments and implementation of community health services, including skilled nursing care, Hospice, adult day health services, respite services, and activities required to successfully transition to the appropriate non-acute care setting.
• Follow up and oversight visits to Veterans after admission to CNH facilities to ensure adequate and safe patient/family education and provider interaction, and implement an education plan to meet the patient care needs.
• Advocate for holistic care through patient/family education and provider interaction and implement an educational plan to meet the patient care needs.
• Provide formal or informal constructive feedback for improvement to peers.
• Support colleagues and other nurses through knowledge sharing to provide high-quality nursing care.
• Evaluate outcomes of evidence-based decisions and practice changes for individuals, groups, and populations.
• Document broad and complex outcomes at the program or service level that can be demonstrated at any organizational level within a facility.
• May serve as the Contract Office Representative (COR) ordering officer whose focus is the development and renewal of community nursing home contracts.
• Work closely with the contracting officer to pursue contracts to meet Veteran's placement and health care needs with the goal of enhancing quality of life and maintaining existing contacts.
• Other duties as assigned.

Requirements

• Basic Requirements: English Language Proficiency - 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).
• Preferred Experience: Geriatric - Nursing Home - Interdisciplinary Team Experience - Consult Management.

Skills

• Must possess and maintain active - unencumbered Driver's License.

Benefits

VA offers a comprehensive total rewards package including:

• 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
• Telework: This position is authorized for telework - situational (ad hoc)
• Relocation/Recruitment Incentives: Not authorized
• EDRP: Not Authorized
• Permanent Change of Station (PCS): Not authorized.