The Community Care Case Manager RN is responsible for executing a streamlined approach to receiving, triaging, and directing timely, coordinated care. The RN Brings principles and theory with application of critical thinking skills. 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.
Major Duties include but are not limited to: Assesses, plans, implements, and evaluates the effectiveness of the Veteran's care Follows procedures per established policies and guidelines Influences care outcomes by collaborating with members of the interdisciplinary team Responsible for executing a streamlined approach to receiving, triaging, and directing timely, coordinated care 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 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 Serves as a liaison to both internal and community providers and is responsible for managing the care of the Veteran throughout the consult process 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 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 Influence care outcomes by collaborating with members of the interdisciplinary team both within the VA and in the community Comply with VA-mandated processes and use of health information solutions that serve to assess, document, exchange, and track care coordination information 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 Knowledge of professional nursing practice and the ability to apply the nursing process (assessment, diagnosis, outcome identification, planning, implementation, and evaluation) Completes orientation according to expected standards Responsible and accountable for individual nursing practice and seeks direction from others as needed Manages workload as assigned, organizes, and completes own assignments in an efficient and appropriate manner Participates in the development, implementation, and evaluation of interdisciplinary care Knowledge of Veteran/patient driven care, patient experience, satisfaction, and safety Establishes a therapeutic relationship, allowing the patient to attain, maintain or regain optimal function through assessment and treatment Engages patients, families, and other caregivers to incorporate knowledge, values, and beliefs into care planning without judgement or discrimination Knowledgeable of ethical issues related to professional nursing practice and follows established policies of the practice setting Aware of high reliability principles to deliver consistent care and improve patient outcomes Communicates, collaborates, and utilizes leadership principles to perform as an effective member of the interprofessional team Incorporates educational resources/opportunities and self evaluation for professional growth Participates in unit based educational activities and continuing education requirements.
Responsible for maintaining competency to continue personal and professional growth Awareness of evidence-based practice/research to improve quality of care and resource utilization Participates in unit-based activities to improve and deliver cost effective patient care Demonstrates knowledge of specific unit level performance improvement activities Meets the needs of the Veteran and as appropriate the Veteran's family, caregiver and/or significant other, the Veteran's representative, visitors to VA facilities, all VA staff and other customers while supporting VA missions 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 - Friday, 8:00am - 4:30pm Compressed/Flexible: Not Authorized Telework: Not Authorized Virtual: This is not a virtual position
Michael.Ferlin@va.gov · 412-654-0531
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $70530 – $142548/yr.
Applications close on 2026-09-23.
This position is open under the 'Fed Internal Search' hiring path.
Source: USAJOBS.gov — U.S. Federal Government
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