The Staff Registered Nurse, Office of Community Care Coordinator and Transition Manger is responsible for facilitating care provided in the community, whether that care is episodic or ongoing. If the care is ongoing, s/he provides support to patients and their family members /caregivers over time as they navigate care and relationships among more than one provider and/or more than one health care setting and/or more than one health service.

Duties

The Care Coordinator/Transition Manager frequently acts on behalf of SFVAHCS with other VA and non-VA care sites and providers to determine availability of clinical services, ensure proper transfer of patient care, participate in collaborative case and care management planning, utilization review and other related case and care coordination activities. The Care Coordinator/Transition Manager acts as an advocate for patients and a team player with colleagues and helps assure patients receive care within the safe and quality care in the community. Collaborates with community providers and community medical staff to transfer patients from non-VA inpatient facilities to VAMCs when stable, to lower levels of care, to refer the Veteran for care within the VA for certain non-VA consult requests , and notifies them when VA follow-up is needed from an episode of unauthorized care all to meet critical needs and achieve positive patient outcomes. Participates in the education and procedural teaching of patients and their significant others, maintaining patient confidentiality and ensuring privacy. Communicate with the veterans and their families to assure understanding of their disease process and the goals of therapy. Collaborates with other healthcare professionals and colleagues, team building activities. Guides and supports staff development from a leadership perspective, using scientific evidence and practice to evaluate programs and/or services and their effectiveness. Demonstrates performance and leadership that is broad enough to facilitate those practices to wider applications when appropriate. Participates in continuing education and achieving and maintaining certification sets a high standard for professional achievement. Looks for " learning opportunities" to acquire and/or teach new skills and functions as a clinical expert. Act as a resource to ancillary staff and facilitate their function as it affects the patients' outcome. Lead and organize delivery of care assures continuity and peer accountability for practice. Contributes to program and organizational success by developing and participating in performance improvement activities. Promotes staff involvement in planning, decision making and evaluating outcomes because it facilitates a supportive environment for all staff to best meet the patient' s individual needs. Ensures that patient data is updated and accurate to ensure continuity of care. Program or service level outcomes must be documented as well, and may be broad and complex. Assist physicians during diagnostic procedures, responding to emergency situations, assessing new treatments , and writing reports may all be functions of the Nurse III. Using their advanced clinical knowledge /judgment to promote staff involvement in planning, decision-making and evaluating outcomes, contributes to organizational success as they improve patient care. Demonstrates clinical competencies in such areas as age specific care, cultural assessment, and health education. Coordinates the process of care with the other team members to maximize efficiency. Documents all patient care activities in a timely manner (per facility policy). Identifies areas for continuing education and participate in in-service training (including staying current with all required education). Develops and implements the performance improvement plans (including quality monitors). Empowers patients and/or caregivers to be active participants in the care/treatment plan. Coordinates care for the patient with the VA referring provider and the community provider. Follows patient though the non-VA episode or continuum of care. Integrates the patient back into the VA system when community care episode is completed. Works independently in the domain of nursing to identify and access community resources that meet individual, group, or population needs. Collaborates with the administrative community care staff to promote fiduciary responsibility and efficiency. 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: 08:00-16:30, Hours varied based on patient and facility needs Telework: 1-2 days/PP Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Financial Disclosure Report: Not required

Requirements

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/12331117. 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. Salary for this position ranges dependent upon applicant qualifications Grade I: $149,816-$199,250 annually Grade II: $172,288-$221,900 annually Grade III: $189,516-$221,900 annually 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: The physical requirements of this position include lifting , prolonged standing, :frequent bending and stooping, walking, reaching, and repetitive motion. Heavy Lifting (45 lbs. and over); Heavy Carrying (45 lbs. and over); Straight Pulling (up to 1 hour); Pushing (1 2 hours); Reaching above shoulder; Use of fingers; Both hands required; Walking (up to 3 hours); Standing (up to 3 hours); Repeated bending (up to 1 hour) ; Ability for rapid mental and muscular coordination simultaneously; Near vision correctable at 13" to 16"; Hearing (aid permitted). The mental/sensory requirements include recall, reasoning, problem solving, hearing, speaking clearly, writing, keyboarding, reading, and logical thinking. The environment's pace can vary from steady to a fast pace requiring handling of multiple priorities, frequent, sometimes intense customer interactions, and the ability to adapt to frequent changes in a sometimes noisy environment. There may be the need to use personal protective equipment to prevent exposure to disease, illness and hazardous materials.

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 Francisco VA Medical Center 4150 Clement Street San Francisco, CA 94121 US
• Name: Angelica Ratliff
• Phone: (415) 221-4810 X22743
• Email: [email protected]