The Care in the Community Nurse is a licensed professional registered nurse assigned to coordinate care for Veterans requesting or referred for care in the community. The RN is responsible for providing the clinical guidance and expertise for the coordination of community care that includes assessment, planning, implementing and evaluating care. Duties include but are not limited to the following: Utilizes multiple approved resources including: Care Management Tool, Consult Toolbox, Impax, JLV (Joint Legacy Viewer), Virtru Pro, FBCS Documents Scanning, Vista Imaging Display, and TriWest Portal. Review requests for Care in the Community, reviews the supporting documentation for completeness and per protocol forwards for approval, medical review or funding. Funds consults when authorized. Utilizes Care Management Tool for complex care coordination along with coordination with VA providers and community provider. Reviews incoming records from the community providers for medical appropriateness and completeness. Assuring scanned results are placed in medical record and attached to the associated consults. Receives calls from veterans and is a resource for helping veterans understand care or treatments as well as the expected process for care in the community. Act as a resource of knowledge for the process care in the community for VA staff. Coordinates care with Internal VA Specialty Providers and/or Primary Care teams on consults and veteran needs. Coordinates care with the Care in the Community APRN and supervising Provider. Collaborates with other health care team members and staff (social workers, travel team etc.) to facilitate complete care of the veteran. Educate and train incoming CITC Nurse staff. Work to develop policy and procedure for the CITC dept. to include team meetings, Appropriately documents nursing interventions in medical record. Maintains a flexible work environment to the changing needs of the office workload and patient needs. Bases care on current evidenced based, best practice standards, knowledge/technological advances and/or research findings. Knowledgeable of the federal regulations for Care in the Community, VHA Guidelines, and care management processes. Identifies personal learning needs and assumes responsibility for own professional growth. Advocates fiscal responsibility in the management of patient care through effective utilization of resources. Maintains a working knowledge of resources available in the community Participates in quality improvement activities. Performs other duties as assigned. Work Schedule: Monday-Friday 7:30 am to 4:00 pm Telework Authorized: Telework to be negotiated with supervisor based on program and agency needs. Financial Disclosure Report: Not required
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.