The Registered Nurse (Home and Community Based Care)/Outpatient provides patient management, care coordination, and discharge/disposition planning for inpatient and outpatient settings. NOTE: The 2-page Resume requirement does not apply to this position.
The Registered Nurse (RN), Home and Community Based Care (HCBC)/Outpatient is responsible and accountable for all elements of the nursing process when providing and/or supervising direct patient care. Assesses, plans, implements, and evaluates care based on age-specific components. Responsible for the coordination of care focused on patient education, self-management, and customer satisfaction throughout the continuum of care.
The RN (HCBC) is responsible for providing competent, evidence-based care to assigned patients. Other duties and responsibilities include, but are not limited to the following: Assists Veterans, family members, and caregivers with receiving the most appropriate options and services to meet their complex health care needs.
This includes, but is not limited to, acute, chronic, multiple, complex, catastrophic, or life-threatening illnesses; combat stress, residuals of traumatic brain injury; community adjustment; addictions and other health problems. Coordinates care with multiple providers across all levels and sites of care. Coordination includes assuring services interface within the Veterans Affairs (VA) and HCBC programs to provide continuity of care to patients.
Performs clinical nursing review of medical records of patients who are hospitalized in non-VA hospitals to determine point of stability for payment purposes and potential for transfer of the Veteran to a VA facility for care. Demonstrates knowledge of utilization management processes, clinical documentation requirements, current standards of care, and compliance guidelines. Maximizes third-party payments for care and delivering quality patient care improvement activities.
Develops and coordinates transitioning of patients throughout the inpatient and outpatient care process with a focus on discharge planning needs. Reviews and assists in patient referrals to HCBC facilities to ensure continuity of qualified comprehensive care.
Participates in the discharge planning assessment and implementation of community health services, to include skilled nursing care, hospice, adult day health services, respite services and activities required to successful transition the patient to the appropriate non-acute care setting. Performs follow-up and oversight visits to the Veteran after admission to HCBC to ensure that adequate and safe care is being provided while under VA contract.
Performs other related duties as listed in functional statement.
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: Full time, 8:00am - 4:30pm, Monday - Friday Telework: No Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized
JUDY.MOSES@VA.GOV · (910) 853-4844
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $82449 – $152684/yr.
This position requires a Other security clearance.
Applications close on 2026-10-19.
This position is open under the 'Fed Internal Search' hiring path.
Source: USAJOBS.gov — U.S. Federal Government
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