Registered Nurse- Community Care Coordinator

The Community Care Coordinator (CCC) is a registered nurse (RN) responsible for care coordination and care management for veterans with clinical triage of moderate and complex, receiving authorized community care. The CCC RN is expected to demonstrate leadership, and innovative approaches in providing care coordination in this complex environment.

The CCC RN utilizes their clinical knowledge and expertise to review referrals and create a care plan to provide care coordination for both pre authorized and emergent episodes of care, following Integrated Veteran Care (IVC) guidance. Major duties include, but are not limited to: Communicates and interacts appropriately and courteously with internal and external customers. Triages and applies a collaborative team approach in identifying, analyzing, and resolving patient care problems. Flexible, adaptable, and versatile; displays the ability to adapt and overcome challenges in a fast paced environment. Maintains confidentiality of patient/employee information electronically, verbally, and written. Coordinates planned and unplanned care for veterans that is safe, effective, equitable and efficient in collaboration with selected community providers. The CCC should have a strong clinical knowledge of common medical conditions requiring follow up after a surgery, procedures and hospitalization. Emphasis on a collaborative process that assesses, advocates, plans, implements, coordinates, monitors and evaluates health care options and services to meet the individual patient's needs. The role of the CCC is to act as a liaison between a Veteran's assigned VA PACT or CC-PCP team, MPLS VA HCS providers and clinics, and non-VA facilities where a Veteran is hospitalized or treated. The CCC ensures a smooth transition of services through specific nursing interventions and thorough care coordination efforts. Provides timely follow-up by addressing phone messages, faxes and alerts accordingly. Assists with calling, sending letters, or emailing communication to Veterans regarding plan of care. Ensures and provides education relevant to the effective progression of care and the appropriate level of care for safe patient transition. Serves as case manager for veterans with Community Care-Primary Care. Maintains communication and track authorizations to prevent a lapse in care, anticipates care coordination needs. BLS certification is required for this position and can be obtained upon hire. Facilitation of referrals and recommendations to support ongoing veteran needs. Demonstrates professional communication, conduct and leadership skills, including willingness to accept increasing levels of accountability. RN should be comfortable with decision-making responsibilities. 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, 7:30am-4:00pm Telework: ADHOC-May be authorized (Employee who Telework on an occasional, episodic, or short-term, and have completed required telework training and telework agreement). Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized 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.

U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. Selective Service Registration is required for males born after 12/31/1959. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical evaluation. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). You may be required to serve a probationary period. Complete all application requirements detailed in the "Required Documents" section of this announcement.