Registered Nurse- Care Coordination and Integrated Case Management

Summary

The Aleda E. Lutz VA Medical Center is recruiting for a Registered Nurse- Care Coordination and Integrated Case Management. The RN Case Manager for Care Coordination and Integrated Case Management (CCICM) will partner with the CCICM Social Worker to implement the national CCICM framework. The goal of this framework is to serve a Veteran population with highly complex health and mental health problems to ensure they receive the right level of care coordination based on their current need.

Duties

• The primary function of the CCICM RN is provide coordination and direct clinical evidence-based services including, assessments and interventions; program development; Veteran, family, caregiver and staff education on Care Coordination and Integrated Case Management (CCICM); resource development; community outreach; continuous quality improvement activities, and evaluation/consultation. Duties include, but are not limited to: Serves as a CCICM subject matter expert. Participates in the development of policies, procedures, and practice guidelines for the program and participates in facility, VISN, and national program development as related to CCICM. Ensures compliance with VHA Directive 1110.04, Integrated Case Management Standards of Practice. Provides guidance and support in the implementation and maintenance of the program through education, training, mentorship, and coaching. Participates in the development of, and implements policies and procedures specific to the Aleda E. Lutz VA Medical Center and ensures compliance with local facility, VISN, Patient Experience Initiatives, VA Central Office (VACO) directives and handbooks, as well as Joint Commission, and other accrediting bodies and regulatory standards as needed. Ensures full collaboration with social work counterpart, for all planning, development, implementation, monitoring, and evaluation of the CCICM operations. Manages, monitors, evaluates and reports on all CCICM related data to fully capture the day-to-day functioning and practice impacts on the facility and Veteran care. Plans, organizes, and directs CCICM operations, in conjunction with the CCICM Executive Sponsor, social work counterpart(s) and the ADPCS. Identifies Veteran cohorts across the Aleda E. Lutz VA Medical Center with the highest opportunity and highest need. Including development and implementation of a monitoring process for ongoing screening and identified cohort(s). Identifies and tracks potential areas where care coordination is taking place to include but not limited to primary care, surgical care, mental health, community care, specialty clinics, geriatrics, chronic disease, and homeless programs. Ensures integration with the facility level care coordination and case management teams to include but not limited to Nurses and Social Workers, care coordinators, care managers, and case managers of, both inpatient and outpatient for seamless continuity of care. Develops, implements and tracks facility wide CCICM education plan to key stakeholders to include Service Chiefs, supervisors/managers, frontline staff, and Veterans with plan for ongoing sustainment. Develops, implement, and monitor processes for ongoing screening and identified cohort. ? Actively participates in the treatment planning process with other disciplines, including involvement in discharge planning with other disciplines and will be responsible for ensuring that discharge plans are executed in a manner that are timely and appropriate. Actively participates in unit quality improvement processes and initiatives, as well as Veteran experience/customer service programs and initiatives. Develops, maintains effective working relationships with key medical center staff and community agencies to enhance the scope and functioning of Veterans assigned. Ability to develop needed community support and/or resources to ensure the program goals are achieved. Provides guidance, education, and direction to the Care Coordination Review Team (CCRT). Ensuring full participation by setting expectations, clear roles, and responsibilities when assigning a Lead Coordinator to Veterans identified as needing moderate or complex care coordination services. Provides direct patient care services to identified high utilizer/at-risk Veterans to ensure appropriate services are in place to support the CCICM framework. Preferred: Candidates in possession of and provide proof of BLS Certification will be considered best qualified. 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: 8:00a- 4:30p, Monday- Friday. Schedule may be subject to change based on the needs of the Agency. Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

Qualifications

Basic Requirements: English Language Proficiency. In accordance with 38 U.S.C. 7403(f), no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English. 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); OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program. Upon achievement of a State license, the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program. (Reference VA Handbook 5005, Appendix G6); OR In cases of graduates of foreign schools of professional nursing, possession of a current, full, active, and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program. Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD). Current, full, active, and unrestricted registration as a graduate professional nurse in a State, Territory or Commonwealth (i.e., Puerto Rico) of the United States, or the District of Columbia. Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements, but do not possess the required licensure, may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.) NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification. Grade Determinations: The following Scope, Education and Dimension criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade. The Dimension requirements (Practice, Veteran/Patient Driven Care, Leadership, Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: https://apply.usastaffing.gov/ViewQuestionnaire/13051765. Grade/Level Scope Education Nurse I, Level I Delivers fundamental, knowledge-based care to assigned clients while developing technical competencies. An Associate Degree (ADN) or Diploma in Nursing, with no additional professional nursing required. Nurse I, Level II Demonstrates integration of biopsychosocial concepts, cognitive skills and technically competent practice in providing care to clients with basic or complex. An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I, Level 1 ;OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required. Nurse I, Level III Demonstrates proficiency in practice based on conscious and deliberate planning. Self-directed in goal setting for managing complex client situations. An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I, Level 2; OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I, Level 2; OR a Master's degree in nursing (MSN) and no additional professional nursing experience; OR a Master's degree in a *related field with a BSN and no additional professional nursing experience. Nurse II Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others. A BSN with 2 years of professional nursing equivalent to Nurse I, Level 3; OR an MSN with one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Master's degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Doctoral degree in Nursing with no professional nursing experience; OR a Doctoral degree in a *related field with a BSN with no additional professional nursing experience. Nurse III Executes position responsibilities that demonstrate leadership, experience and creative approaches to management of complex client care beyond the immediate practice setting. MSN and 2 years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Master's degree in *related field with BSN and two years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III. *Note: Foreign education programs/degrees are not creditable as related degrees. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. Physical Requirements: This clinical position includes a level of physicality normally associated with direct patient care duties performed by nurses for potentially long periods of time. This may include walking, standing, stooping, bending, sitting, reaching, pushing, and pulling. It may include moderate lifting/carrying, not greater than 35 pounds following Safe Patient Handling and Mobility (SPHM) guidelines. Employees are expected to employ proper body mechanics during lifting and seek assistance or use mechanical lifts for weights greater than 35 pounds following Safe Patient Handling Guidelines. Requires adequate vision to accurately perform the assigned duties, distinguish basic colors and assess patients and the environment safely. The position requires the ability to hear at a level to perform the assigned duties, and the use of hearing aids is permitted. This position potentially requires flexibility in schedule and assignments.

Requirements

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.

Education

To meet qualification requirements, your resume should clearly identity the following information for each applicable degree: Name of the college or university Degree earned and the field of study Date the degree was conferred (month and year) Please ensure this information is included directly on your resume so your education can be properly evluauated during the qualification review.

How to apply

All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 09/10/2026 to receive consideration. To preview the questionnaire, click https://apply.usastaffing.gov/ViewQuestionnaire/13051765. To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire. Click Submit My Answers to submit your application package. NOTE: It is your responsibility to ensure your responses and appropriate documentation are submitted prior to the closing date. During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions.