Registered Nurse - Collaborative Care Case Manager

Overview

The Collaborative Care Case Manager (CCCM) is a professional registered nurse responsible and accountable for indirect patient care by demonstrating leadership in delivering and improving holistic care through collaborative strategies with all disciplines for Veterans within The Syracuse VA Medical Center. The CCCM facilitates patient care and improves patient flow from admission to discharge, providing professional assistance in anticipation of patient’s needs.

The CCCM inputs data into the NUMI program to determine the appropriate level of care and utilizes the NUMI data to develop a patient‑centered interdisciplinary discharge plan. The CCCM works collaboratively with diagnostic and ancillary services related to tests, procedures, and appointments to improve patient flow and throughput. The CCCM exhibits excellent relationship skills that facilitate communicating patient needs, appropriate level of care, and barriers related to throughput with all members of the health care team.

The CCCM leads the interdisciplinary team meetings to discuss planned or anticipated discharges within 24‑48 hours. The CCCM facilitates and coordinates the discharge plan by placing travel consults, scheduling discharge appointments, ordering appropriate home‑going supplies, placing prosthetic consults, monitoring clinical reminders for the pneumovax vaccine, influenza vaccine, PPDs and other reminders appropriate for the facilitation of the discharge plan. The CCCM completes GECs, RUGs and monitors home‑care referrals.

The CCCM acts as a resource coordinator by notifying appropriate nursing staff and other health care team members regarding the discharge plan. The CCCM is administratively responsible to the Nurse Manager, Patient Transfer Center and works collaboratively with the Chief of the Patient Transfer Center, Chief of Patient Care Administrative Services, attending physicians, house staff (residents and interns), mid‑level providers and staff at all levels throughout the Medical Center and outpatient care system.

• Completion of NUMI and patient continuing stay criteria
• Facilitate discharge planning meeting and discussions
• Travel consults
• Assist with scheduling of discharge appointments
• Arrange for appropriate home‑care supplies
• Complete clinical reminders
• RUG scores
• PRI screening
• Admission and discharge education
• Documentation and communication with interdisciplinary team
• Assist with LST and Advanced Directives
• Collaborate with ancillary services
• GM 90 screenings
• Assist with transfers in and out of facility
• Assist with patient flow
• Other duties as assigned

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 401(k) 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: Monday – Friday 07:30‑16:00
Telework: Not Available
Virtual: This is not a virtual position.
Permanent Change of Station (PCS): Not Authorized

None specified in the posting.