Registered Nurse - Community Care Coordinator

Created at: October 07, 2025 00:14

Company: Veterans Health Administration

Location: Beckley, WV, 25801

Job Description:

The Registered Nurse, Community Care Coordinator assesses, plans, implements, and evaluates care based on age specific components. They assume responsibility for the coordination of care focused on patient education, self-management, and customer satisfaction throughout the continuum of care. They influence care outcomes by collaborating with members of the interdisciplinary team and demonstrate creative approaches to the management of complex client care.
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: . 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 requires visual acuity, keen hearing, clear distinctive speech, and manual dexterity. This position requires potentially long periods of continued walking, standing, stooping, sitting, bending, pulling, lifting 10 pounds or more and pushing. Transferring patients and objects may be required. May be exposed to infected patients and contaminated materials and may be required to don protective clothing in isolation situations or operative/invasive procedures. May Occasionally be exposed to patients who are combative secondary to delirium, dementia, or psychiatric disorders. Must be a mature, flexible, sensible individual capable of working effectively in stressful situations, able to shift priorities based on patient needs.
Major duties include, but are not limited to: Delivers safe care to assigned patients, while developing technical competencies. Safely and effectively uses patient care equipment. Correctly and safely performs nursing procedures. Demonstrates flexibility/adaptability to maximize available resources to ensure comprehensive, effective healthcare delivery. Identifies and assesses resources (financial, human, delegating, and adjusting assignments and willingly assisting/leading co-workers when needed. Enters consults/orders to include, but not limited to, Prosthetics and Durable Medical Equipment (DME) request, continuation of care consults, imaging, labs, etc. Recognizes overt abnormal signs and symptoms and/or changes in patient's condition and responds appropriately. Implements provider's orders in a timely and complete manner. Implements nursing interventions/orders in a timely and complete manner. Participates in the development, implementation, and evaluation of interdisciplinary care. Documents the nursing process Documentation is consistent, accurate, concise, and timely. Evaluates and documents patient response to interventions and progress towards attainment of goals and expected outcomes. Demonstrates flexibility by collaborating with all levels of internal and external customers to facilitate improvement within available resources. Knowledgeable of ethical issues related to professional nursing practice and follows established policies of the practice setting, VA, and ANA Code of Ethics for Nurses. Listens to and honors patient and family perspectives and choices. Patient and family knowledge, values, beliefs, and cultural backgrounds are incorporated into the planning and delivery of care in a non-judgmental, non-discriminatory manner (Patient and Family Centered Care). Maintains professional boundaries with patients, families, and employees. Behavior as a role model is transparent and above reproach. Identifies, analyzes, and alerts the next level supervisor regarding ethical/legal issues related to nursing practice to promote timely resolutions. Serves as an advocate for the patient and family to ensure their partnership in the plan of care and decision-making regarding the care provided. Maintains patient confidentiality by not discussing patient information except when necessary to authorized staff only in order to meet health care needs. Ensures application of institutional policy to protect information from unauthorized release, loss, alteration, or deletion. Does not use thumb-drives or other means, such as xeroxing, to remove patient data from the medical center, unless approved and granted by facility approving officials. Formulates a plan of care based on nursing assessments, using the nursing process, based on the ANA Standards of Nursing Practice. Completes initial assessment of patient condition and response to treatment and initiates follow-up as needed. Includes the patient and family/significant other in developing the initial plan of care and establishing goals. Updates plan of care with assistance as needed. Assesses patient's learning needs, learning preference and readiness to learn. Participates in Veterans Health Administration High Reliability Organization and I CARE implementation practices and trainings (i.e., Safety Huddles, Clinical Team Training, and baseline HRO trainings). Identifies resource requirements for defined patient population based on plans of care. 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 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: Full-Time, Monday-Friday; 8:00am-4:30pm Telework: Not available. Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not authorized. Permanent Change of Station (PCS): Not authorized.


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