Veterans Affairs, Veterans Health Administration Registered Nurse Transfer Center Discharge Planner in San Diego, California
Summary The Transfer Center is built on a patient and family centered approach and delivered by an interdisciplinary team which exists both within and outside the VA San Diego Healthcare System (VASDHS). The VASDHS Utilization Management's Transfer Center consists of three care coordination roles: Discharge Planner, Clinical Transfer Coordinator and Traveling Veteran Coordinator (TVC). Responsibilities - Facilitates the movement of Veterans between VASDHS and other VA facilities and community agencies. - Works with the Nursing & Patient Care Services leadership in the flow of patients from VASDHS to other-VA medical facilities and community facilities when necessary. - Serves as a point-of-contact for VA and community agencies seeking admission to VASDHS. - Works with other-VA and community Nurse Case Managers, Transfer Coordinators, physicians, and administrators seeking services from VASDHS. - Utilizes InterQual criteria to identify medical necessity and intensity of service for transfer referrals. a. Documented outcomes of utilization management in their respective assigned areas where resource utilization is impacted, and clinical decisions are made that have potential to alter the course of patient care and VASDHS. - Determines level of care and refers requests to appropriate Services/Case Managers for transfer consideration. - Discusses Veteran transfer concerns with an interdisciplinary team (physicians, social workers, case managers, pharmacists and nutritionist). a. Act as patient and family advocate b. Assesses clinical outcomes - Locates scarce medical resources for VASDHS patients being referred out to the community. - Coordinates the modes of transportation used in the transfer process i.e. ambulance, critical air, and secure transport. - The Clinical Transfer Coordinator and/or TVC facilitates appropriate consults in accordance with the Coordinated Care for Traveling Veterans directive (1101.11). - Collaborates with utilization review and transitions to different clinical settings for VASDHS and is involved in interdisciplinary medical center resource utilization. - Act as a liaison, providing a bridge between caregivers within and outside the VASDHS for emerging medical, psychosocial, or rehabilitation problems, managing the continuum of care and care coordination. - The TVC is responsible and accountable for ensuring Veterans on extended travel will have their anticipated and unexpected medical needs coordinated by their preferred and alternate facility to prevent any disruption in care and by executing needs as a preferred or alternate facility depending on the received request. - The Discharge Planner will develop and coordinate seamless transitioning of patients throughout the inpatient and outpatient care process with a focus on discharge planning needs. Demonstrates knowledge and ability to apply principles of evidence-based practice. A key aspect of the role will be discharge planning assessment and implementation of home health services, supplies, and activities required to successful transition the patient to the appropriate non-acute care setting. Work Schedule: Full time, permanent, 40 hours, Monday - Friday, tour between the hours of 06:30 a.m.-19:00 p.m. Off-tours, Overtime / Weekend / Holiday may be required to meet patient care needs. Shifts require flexibility and exact work schedule to be discussed during interview. Financial Disclosure Report: Not required Requirements Conditions of Employment 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. Graduate of a school of professional nursing approved by the appropriate State-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). In cases of graduates of foreign schools of professional nursing, possession of current, full, active and unrestricted registration will meet the requirement of graduation from an approved school of professional nursing. OR The completion of coursework equivalent to a nursing degree in a MSN Bridge Program that qualifies for professional nursing registration constitutes the completion of an approved course of study of professional nursing. Students should submit the certificate of professional nursing to sit for the NCLEX to the VA along with a copy of the MSN transcript. (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. 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. Preferred Experience: BSN or MSN or related field; recent 3-5 years experience in Critical Care, Emergency Room, Medical/Surgical, Utilization/Case Management or Utilization Reviewer, program development, data tracking, management, analysis of results experience; expertise in Microsoft software; excellent interpersonal skills; worked independently while collaborated with other services; review clinical records and provide prospective recommendation; and self-motivated. 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 - An Associate Degree (ADN) or Diploma in Nursing, with no additional nursing practice/experience required. Nurse I Level II - An ADN or Diploma in Nursing and approximately 1 year of nursing practice/experience; OR an ADN or Diploma in Nursing and a bachelor's degree in a related field with no additional nursing practice/experience; OR a Bachelor's of Science in Nursing (BSN) with no additional nursing practice/experience. Nurse I Level III - An ADN or Diploma in Nursing and approximately 2-3 years of nursing practice/experience; OR an ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 1-2 years of nursing practice/experience; OR a BSN with approximately 1-2 years of nursing practice/experience; OR a Master's degree in nursing (MSN) or related field with a BSN and no additional nursing practice/experience. Nurse II - A BSN with approximately 2-3 years of nursing practice/experience; OR ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 2-3 year's of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 year's of nursing practice/experience; OR a Doctoral degree in nursing or meets basic requirements for appointment and has doctoral degree in a related field with no additional nursing practice/experience required. Nurse III - Master's degree in nursing or related field with BSN and approximately 2-3 year's of nursing practice/experience [If MSN obtained in a Bridge Program, no BSN is required.]; OR a Doctoral degree. 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: Heavy Lifting and Carrying (45 lbs and over); Straight Pulling, Pushing, Walking, Standing, Kneeling, Repeated bending, Keyboarding, Viewing computer screen (8 - 12 hours); Reaching above shoulder; Use of fingers; Both hands and legs required; Ability for rapid mental and muscular coordination simultaneously; Near vision correctable at 13" to 16" to Jaeger 1 to 4; Far vision correctable in one eye to 20/20 and 20/40 in the other; Depth perception; Ability to distinguish basic colors and shades of colors; Hearing (aid permitted); and Emotional/Mental stability. 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: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html. Additional Information Annual leave shall accrue for full-time Nurses, and Nurse Anesthetists at the rate of 8 hours for each full biweekly pay period. This job opportunity announcement may be used to fill additional vacancies. It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment. 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. 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. If you are unable to apply online view the following link for information regarding an Alternate Application.