The Registered Nurse Care Coordinator (RNCC) is responsible for (deliberate) organization of patient and family-centered care activities between two or more participants in which the RNCC uses advanced critical thinking to develop, implement, and evaluate individualized care plan to empower patients and optimize outcomes. The RNCC marshals and coordinates resources and patient care activities to support transition management, through collaboration across the continuum, supporting patient and families’ needs for individualized follow-up and coordination of services across healthcare services and locations. This job profile integrates the ANA Nursing: Scope and Standards of Practice the ANA Code of Ethics for Nurses with Interpretive Statements the AAACN Scope & Standards of Practice for Professional Ambulatory Care Nursing and the AAACN Scope and Standards of Practice for Registered Nurses in Care Coordination and Transition Management, with the UVA Nursing Professional Practice Model. Virginia at Home (VaH) offers home-based primary care for older adults who are homebound due to medical, functional, or cognitive issues. The program focuses on patient-centered care, helping participants stay in their preferred environments while reducing unnecessary hospital visits. Services include house calls, caregiver support, and Advance Care Planning. We are looking for a dedicated, compassionate RN to join our team. This full-time role will provide essential care coordination to this high-risk, high-needs, geriatric population. This role will also support the VaH Provider Team in developing and executing the plan of care. RN Care Coordinator interventions will include patient assessments and patient education during home visits or telephone calls. Other duties will include covering the nurse triage line, specimen collection and vaccine administration during a home visit, when needed. A reliable vehicle is required for travel, with mileage reimbursed. Care coordination and transition management necessitates professional assessment, patient risk identification and stratification, and identification of individual patient needs and preferences that include but are not limited to the RNCC: + Demonstrating the use of the UVA Professional Practice Model through nursing professional practice, quality achievement, lifelong learning, empowered leaders, innovation, and expert caring. + Planning, coordinating, and prioritizing patient care activities considering patients' unique needs and desired outcomes in collaboration with the inter-professional team including consult recommendations and escalation as needed. + Maintaining safety and continuity of care using methods such as documentation, hand-off tools/processes, etc. + Collaborating and advising patients, families, and caregivers in their healthcare decisions, respecting their culture and values. + Providing health education and coaching to patients tailored to issues identified within treatment and service plans through evidence-based care delivery and safety standards. + Providing facilitative leadership that promotes health equity across the continuum and among interdisciplinary teams to improve population health, patient experience, and cost reduction. + Demonstrating knowledge and ability to participate in and apply research and evidence-based practices for the improvement of patient care throughout the lifespan and across the continuum. + Taking the lead in ensuring the continuity and consistency of care across the continuum to promote and facilitate pre-visit coordination, post-clinic follow-up, and handoff between services, along with monitoring and facilitating transitions of care. + Educating patients & families with chronic illness about evidence-based standards of practice to empower patients to include self-management strategies. + Identifying support needs and developing action plans and guidance to initiate patient-centered care planning and application of the nursing process. + Contributing to problem-solving through communication and collaboration and evaluating outcomes of treatment options to include tracking patient progress toward care plans and goals. + Supporting medication management + Other duties as assigned. + UVA Nursing Professional Practice Model + **Relationship Based Care - Self and Colleagues:** reflects the influence of the nurse's relationship with self, colleagues, and patient/family on the patient's experience. + **Relationship Based Care - Patients and Families:** reflects the influence of the nurse's relationship with self, colleagues, and patient/family on the patient's experience. + **Expert Caring:** encompasses clinical assessment, planning, prioritizing, coordinating, and implementation of care. + **Empowered Leaders:** demonstrate knowledge of and actively participate in shared governance + **Lifelong Learners:** encompasses professional development through formal education, professional certification, and internal and external learning opportunities and recognizes the value of external professional organizations. Supports onboarding of new team members and precepts as applicable. + **Quality Achievement** : includes adherence to clinical documentation guidelines, comprehension of outcomes data, engagement in performance improvement activities, and commitment to standard work. + **Innovation:** is demonstrated by the application of technologies that support patient care, actively seeking to implement evidence-based practice and new knowledge generated by nursing research. Position Compensation Range: $85,820.80 - $113,401.60 Annual **MINIMUM REQUIREMENTS:** + Education: Bachelor of Science in Nursing from an accredited nursing program. + Experience: Experience: 1 year of registered nursing experience required, 3 years of related and relevant registered nursing experience strongly preferred. + Specialty Board Certification strongly preferred + License/Certification: Licensed to Practice as a Registered Nurse in the Commonwealth of Virginia. American Heart Association (AHA) Health Care Provider BLS certification is required. **PHYSICAL DEMANDS** Job requires standing for prolonged periods, frequently traveling, and bending/stooping. Proficient communicative, auditory, and visual skills; Attention to detail and ability to write legibly; Ability to lift/push/pull 20 - 50lbs. May be exposed to chemicals, blood/body fluids, and infectious diseases. _The_ _University of Virginia is an equal opportunity employer. All interested persons are encouraged to apply, including veterans and individuals with disabilities. Click_ here (https://eocr.virginia.edu/notice-non-discrimination-and-equal-opportunity) _to read more about UVA’s commitment to non-discrimination and equal opportunity employment._