Nurse (Case Manager/Home Health)

About the role

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.

What you will do

• 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

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 (***).
• 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 you will be evaluated

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC.

WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE.

Your application, resume, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

NOTE: Candidate's education, scope, and length of nursing practice (experience) will be considered in determining the grade and salary of the applicant selected. The recommended salary may be at any point in the range listed for this vacancy.

Experience as an RN will be evaluated to determine if the experience is of an acceptable level of quality with regard to the following five dimensions of nursing: Practice, Veteran/Patient Driven Care, Leadership, Professional Development, and Evidence/Based Practice/Research.

Each dimension of practice has criteria that demonstrate essential core competencies for VHA Nursing Personnel. Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social).

Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.

The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position.

It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.

Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.

Documents you must provide

• Long-form resume/Curriculum vitae (CV) SF-50/ Notification of Personnel Action Transcript The following documents are accepted and may be required if applicable to your eligibility and/or qualifications for this position.
• Cover Letter DD-214/ Statement of Service Disability Letter (VA) License Long-form resume/Curriculum vitae (CV) Other (1) Professional Certification SF-50/ Notification of Personnel Action Transcript Veterans' Preference Note: Preference-eligible candidates and other Veterans will be given preference when qualifications of candidates are approximately equal for Title 38 positions in VHA.
• When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire.
• You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.).
• If you are currently serving on active duty and expect to be released or discharged within 120 days, you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation.
• Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form.
• Documentation is required to award preference.
• For more information on Veterans' Preference, please visit Feds Hire Vets - Veterans - Job Seekers - Veterans' Preference.

What to expect next

Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met.

After the review is complete, a referral certificate(s) is issued, and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.

You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center. NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).

It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccination has been granted. HCP in violation of this directive may face disciplinary action up to and including removal from federal service.

HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities.

HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities.

HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.

Additional information

This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply.

The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement.

Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.