The RN Case Manager/Care Coordinator for the Community Living Center is an RN who coordinates care for a group of residents admitted in the CLC. He/she demonstrates expertise in application of the nursing process to the RAI/MDS assessment and interdisciplinary care plans. He/she is responsible for assessing the resident in order to complete the MDS/VA Care nursing assessment subsequently completing the Care Assessment Areas (CAAs) and developing the care plan as per established time frames.

Duties

The RN Case Manager/ Care Coordinator is responsible for assessing the resident in order to complete the MDS/VA Care nursing assessment subsequently completing the Care Assessment Areas (CAAs) and developing the care plan as per established time frames. He/she works in team with the Permanent Charge Nurse (PCN) and Team RNs and the interdisciplinary team to develop the care plan and to assure that the resident's care plan goals and approaches are carried out, revised as needed and modified between team meetings. He/she collaborates with the interdisciplinary team members to assure the interdisciplinary care plan is personalized and reflects the resident's desired goals and approaches. He/she assures that the care plan is an accurate guide for the resident's individualized care and that direct care providers have input and access to the plan of care to ensure the plan is implemented and the resident's goals achieved. He/she establishes the date for discussion of the interdisciplinary care plan, in accordance with the CMS Standards, and leads the care planning meeting. He/she reports the final plan to team members not available to participate in the care planning meeting. He/she actively participates in the neighborhood morning reports, sharing their expertise regarding MDS and Restorative care, influencing others to use MDS as the driver of care. He/she demonstrates a high level of clinical and leadership skills and is competent in utilizing the MDS/ VA Care process as the driver of care. He/she evaluates the MDS Quality Measures (QM), analyzes the reasons why residents trigger the MDS QM and establishes an action plan in conjunction with the nursing staff and interdisciplinary team; subsequently he/she evaluates the action plan and makes changes accordingly. He/she is competent in conduction and reporting performance improvement indicators and maintains the MDS 802 updated. He/she performs the MDS Inter-Rater reports and Adhoc reports. He/she possesses knowledge of the CMS Standards, the application to the comprehensive MDS/ VA Care assessment process and restorative care modalities. He/she coordinates the restorative care program, determines potential candidates for restorative care, implements or directs the restorative care modalities and determines the resident's need for continuance in the program or discharge. He/she completes the restorative care assessment, accordingly. He/she send as a consultant to the LTC Screening Committee and evaluates candidates that are consulted to LTC to determine potential for admission under the Restorative Care Treating Specialty. He/she ensures that restorative research findings and practice are incorporated into clinical practice and delivery of care; ensures that staff integrate the restorative modalities outlined in the resident's care plan into the daily routine. He/she assures that residents receive appropriate restorative services, including assistance with activities of daily living, such as eating, dressing, grooming, bathing, oral hygiene, ambulation and toilet activities. He/she coordinates to assure resident have the appropriate supplies and equipment needed to support self-care and that adaptive self-help devices are provided when needed. He/she assures that all reasonable steps are taken to keep residents in the Restorative Program safe from accident and injury. He/she works closely with the Restorative Care Coordinator LPN and/or with the staff providing direct resident care to ensure that residents reach their restorative care goals. The RNCC promotes discussions of cases utilizing the Watch List Huddles with the interdisciplinary team and direct care staff to avoid falls, behaviors, visits to emergency department visit and rehospitalizations, among others. Work Schedule: Monday - Friday, 7:30am-4pm Telework: Not available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not authorized Permanent Change of Station (PCS): Not authorized Financial Disclosure Report: Not required

Requirements

Qualifications

Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency. Candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C. § 7403(f). Graduate of a school of professional nursing: Nursing education must be from a school of professional nursing accredited by one of the following at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN): accredits all levels of nursing programs, including clinical doctorate, masters/post master's certificate, baccalaureate, associate and diploma nursing education programs. (Note: The National League for Nursing Accrediting Commission/NLNAC changed its name to ACEN in May 2013. however, for verification of any nursing program's accreditation prior to 1998, ACEN must be contacted directly via their email on the ACEN website to verify.) or The Commission on Collegiate Nursing Education (CCNE): an accrediting arm of the American Association of Colleges of Nursing (AACN) and accredits nursing education programs at the bachelor and master's level. 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. Nursing bridge programs are accelerated nurse education programs which rely upon existing nursing knowledge and education. Graduates from nursing bridge programs that meet accreditation requirements specific grade level requirements in this standard must also be met in addition to the following: Master's Level Bridge Program Education Appointments Prior to Graduation. Individuals attending a master's level bridge program in nursing who achieve the level in their education in which they 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 a temporary basis for any period up to three years contingent upon full completion of the professional nursing education program, if education verification provided by the school supports the Bachelor of Science in Nursing (BSN) equivalency. Upon successful completion and graduation from the bridge program, the Nurse may be converted to a permanent appointment under the provisions of section 7401(a)(1) of title 38. Failure to complete the bridge program on which the temporary appointment was based will result in termination of the appointment. Foreign Education: Graduates of foreign schools of professional nursing who possess a current, full, active and unrestricted registration will meet the requirement of graduation from an approved school of professional nursing to warrant appointment as a Nurse who has completed an associate degree level Nursing education program. To grant credit towards an appointment based on foreign nursing education higher than the associate degree level, formal degree equivalency validation from a recognized degree equivalency evaluation agency accepted by VA such as the International Consultants of Delaware (ICD) must be obtained. Preferred Experience: (See Additional Information) Grade Determinations: The following criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade: Nurse I Level I - (a) An Associate Degree (ADN) or Diploma in Nursing, with no additional nursing practice/experience required. (b) Scope: Delivers fundamental, knowledge-based care to assigned clients while developing technical competencies. Nurse I Level II - (a) An ADN or Diploma in Nursing or One year of specialized nursing experience equivalent to a Nurse I, Level 1; OR a Bachelor's of Science in Nursing (BSN) with no additional nursing practice/experience.(b) Scope: Demonstrates integration of biopsychosocial concepts,cognitive skills and technically competent practice in providing care to clients with basic or complex. Nurse I Level III - (a) An ADN or Diploma in Nursing and Two years of professional nursing practice, one of which is a year of specialized nursing experience equivalent to Nurse I, Level 2; OR a BSN with One year of professional nursing experience equivalent to Nurse I, Level 2; OR Master's degree in Nursing and no No professional nursing experience; OR a Master's degree in nursing (MSN) or related field with a a bachelor's degree in nursing and no additional nursing practice/experience. (b) Scope: Demonstrates proficiency in practice based on conscious and deliberate planning. Self-directed in goal setting for managing complex client situations. Nurse II - (a) BSN with Two years of professional nursing experience, one of which is a year of specialized nursing experience equivalent to Nurse I, Level 3; OR Master's degree in nursing and One year of specialized nursing experience equivalent to Nurse I, Level 3; Master's degree in a related field with a bachelor's degree in nursing and One year of specialized nursing experience equivalent to Nurse I, Level 3; Doctorate degree in nursing no professional nursing practice; Doctorate degree in a related field with a master's or bachelor's degree in nursing no professional nursing practice. (b) Scope: Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others. Nurse III - (a) Master's degree in nursing with two years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; Master's degree in a related field with a bachelor's degree in nursing with Two years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; Doctorate degree in nursing with One year of specialized nursing experience which is equivalent to Nurse II and meets all dimension requirements for Nurse III; Doctorate degree in a related field with a master's or bachelor's degree in nursing with One year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III. (b) Scope. Executes position responsibilities that demonstrate leadership, experience and creative approaches to management of complex client care beyond the immediate practice setting.(c) Dimension Requirement. Nurses at Nurse III must meet ALL the following dimension requirements to qualify for Nurse III; i Practice. Demonstrates expertise in professional practice using the nursing process (assessment, diagnosis, outcome identification, planning, implementation and evaluation) with improved evidence-based and/or data-driven outcomes beyond the immediate practice setting; ii Veteran/Patient Driven Care. Leads initiatives to improve Veteran/patient experience. Satisfaction and/or safety beyond the immediate practice setting; iii Leadership. Communicates and collaborates as an effective leader of the inter professional team, at the expert level, with improved evidence-based and/or data-driven outcomes beyond the immediate practice setting. iv Professional Development. Enhances knowledge base and practice evaluation, at the expert level, with improved outcomes beyond the immediate practice setting. v Evidence Based Practice/Research. Leads the identification and integration of evidence-based practice/research with clinical expertise to improve quality of care and resource utilization at the expert level with improved outcomes beyond the immediate practice setting. Reference: VA Regulations, specifically VA Handbook 5005, Part II, Appendix G-6 Nurse Qualification Standard. This can be found in the local Human Resources Office Physical Requirements: (See Additional Information)

Education

IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

Contacts

• Address San Juan VA Medical Center 10 Calle Casia San Juan, PR 00921 US
• Name: Luis Burgos-Pena
• Email: [email protected]