Nurse (Case Manager/Home Health)

Summary

Responsible and accountable for all elements of the nursing process when providing or supervising direct patient care. Assesses, plans, implements, and evaluates care based on age-specific components. Assumes responsibility for the coordination of care focused on patient education, self-management, and customer satisfaction throughout the continuum of care. Follows procedures per established policies and guidelines. Influences care outcomes by collaborating with interdisciplinary team members.

Duties

• VA offers a comprehensive total rewards package: VA Nurse Total Rewards Listed duties are at the Full Position Level III. Functions or Scope of Assigned Duties include, but are not limited to: The Nurse Acute Care Case Management (CM) Registered Nurse (RN) executes position responsibilities that demonstrate leadership, experience, and creative approaches in providing complex patient management. Provides patient management, care coordination, and discharge/disposition planning for inpatient and outpatient settings. The CM RN 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. The CM RN addresses psychosocial, as well as nursing and medical needs of patients and their families/caregivers, through participation in interdisciplinary patient care management practice. The CM RN also evaluates care and outcomes to ensure timely and appropriate provision of services. Demonstrates performance and leadership that is broad enough to improve the care for a group of patients. Supports colleagues and other nurses through CM knowledge sharing to provide safe, quality nursing care. Fosters a safe and supportive environment conducive to the professional development of health care professionals. Evaluates CM outcomes of evidence-based decisions and practice changes for individuals, groups, and populations. Responsible for the documented CM outcomes at the program or service level. Provides initial and ongoing assessment of patients to identify needs, issues, resources, and care goals, and identifies resources and critical factors for achieving desired outcomes for discharge, post-hospitalization recovery, and health maintenance/improvement. Responsible for delivery of quality care by using case management functions such as assessment, intervention, evaluation, and safe discharge planning, including appropriate documentation. Screens patients within 24-48 hours of admission, utilizing data from standardized sources to identify the appropriate intensity of case management required. Prioritizes the patients in need for case management. Screens patients for social service, home care, and other community care needs; and coordinates or makes referrals as appropriate; and seeks consultation when indicated. Develops Interdisciplinary Treatment Plan with measurable and objective goals, in collaboration with the patient, family, provider, and members of the interdisciplinary care team for all patients identified requiring complex level of case management. Works collaboratively with the interdisciplinary groups in a cohesive manner. Appropriately documents interventions and oversees appropriate health team documentation of patient care. Able to access and interpret patient data gathered during patient rounds. Actively participates in interdisciplinary team meetings and is competent in documenting in the GUI, VISTA, and CPRS systems about the patient's social, emotional, mental health, and medical needs. Collaborates with all the interdisciplinary members of the team, including physicians, nurses, social workers, Utilization Management team, Extended Care teams, and VA CLC staff, for program development, quality care, and resource planning. Keeps the interdisciplinary team aware of the progress, plan, and barriers. Conducts daily reviews of all the assigned patients' records for utilization management by using the InterQual Guidelines and documenting the criteria under the National Utilization Management Integration (NUMI) program mandated at the VA National level. Complete annual training in Acute Adult and Behavioral Health and achieve a passing score of 80% or higher passing (80%) of yearly Optum InterQual Competency test. Advocates fiscal responsibility in the management of patient care through effective utilization of resources. Other Duties as assigned 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-year 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 U.S. state or territory Work Schedule: M-F 7:00 am - 3:00 pm or as determined by the supervisor. Compressed/Flexible: This may be authorized at the supervisor's discretion. Telework: Not Available Virtual: This is not a virtual position

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 the 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 a 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/13058024. 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 position includes a level of physicality normally associated with duties performed by nurses such as direct patient care, and potentially long periods of walking, standing, sitting, moderate lifting, repeated bending, or kneeling. Examples may include but are not limited to: Significant amounts of time standing assisting assigned patients. Utilization of safe patient handling and mobility protocols

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 a pre-employment physical evaluation/examination. 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.

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 09/16/2026 to receive consideration. To preview the questionnaire, click https://apply.usastaffing.gov/ViewQuestionnaire/13058024. To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USAJOBS 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.