The Registered Nurse (RN) in this role coordinates and manages discharge planning for surgical patients, ensuring safe, timely, and well-coordinated transitions from inpatient surgical care to home, rehabilitation, or other post-acute settings.
The VA Midwest Health Care Network advocates for a Whole Health System of care in each of the Medical Centers. This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest. As an employee operating in a Whole Health System of care, you will operate in a model with three core elements, seeking to create a personalized health plan for each Veteran.
This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community. This aligns with the Veterans Health Administration (VHA) Mission Statement to Honor America's Veterans by providing exceptional health care that improves their health and well-being.
Duties include, but not limited to: Conduct early and ongoing assessment of surgical patients' discharge needs, including mobility, wound care, medication management, and support systems. Collaborate with surgeons, nursing staff, physical/occupational therapy, social work, and case management to develop individualized discharge plans.
Educate patients and caregivers on post-surgical care, including wound care, activity restrictions, medication regimens, and warning signs requiring follow-up. Coordinate referrals for home health, durable medical equipment, skilled nursing facilities, or outpatient rehabilitation as needed. Identify and address barriers to discharge (e.g., housing instability, lack of caregiver support, transportation) in coordination with social work.
Ensure discharge documentation is accurate, complete, and compliant with facility and regulatory standards. Schedule and confirm follow-up appointments prior to discharge. Monitor and help reduce avoidable readmissions through proactive discharge planning. Communicate discharge plans clearly to the patient, family, and receiving care providers. Participate in interdisciplinary rounds and discharge planning meetings.
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 to Friday, 7:00am to 3:30pm Telework: Not Available Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized
kelsie.niuvela@va.gov · 2532092056
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $65500 – $140292/yr.
Applications close on 2026-10-22.
This position is open under the 'Fed Internal Search' hiring path.
Source: USAJOBS.gov — U.S. Federal Government · Retrieved 2026-10-14 · Not affiliated with or endorsed by OPM or USAJOBS.gov
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