- Provide longitudinal case management for high-risk Veterans with complex chronic and behavioral health conditions.
- Perform comprehensive biopsychosocial assessments and develop individualized, goal-oriented care plans.
- Coordinate care across primary care, specialty services, mental health, community resources, and non-VA providers.
- Use risk-stratification tools to identify high-risk Veterans and prioritize interventions to reduce avoidable ED visits and hospitalizations.
- Manage transitions of care, ensuring timely follow-up, medication reconciliation, and continuity of care plans.
- Collaborate with interdisciplinary teams and facilitate case conferences for medically or psychosocially complex Veterans.
- Promote Veteran engagement, self-management, and access to needed services while ensuring culturally competent care.
- Monitor clinical indicators, escalate care when needed, and support evidence-based chronic disease management.
- Maintain accurate, timely EHR documentation and track coordination activities, outcomes, and quality measures.
- Provide care via phone, video, secure messaging, and in-person interactions to support continuous, proactive care.
- Participate in quality improvement, population health initiatives, and program evaluation efforts.
- Identify and respond to safety concerns, including clinical deterioration or behavioral health crises, and collaborate with mental health services.
- Maintain professional licensure, meet training requirements, and adhere to VA policies and nursing standards.
- Face to Face visits with Veterans in Emergency Department, Inpatient Units and accompany to Specialty Care appointments.
Preferred Experience: 2 years outpatient case management experience preferred
Work Schedule: Monday thru Friday, 7:30 am to 4:00 pm
Telework: Not Available
Virtual: This is not a virtual position.
Location: Main Hospital, 6900 N. Pecos Rd, North Las Vegas NV 89086
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required
FS #: 09865-F, 09866-F, 09867F, 09868-F, 09869-F