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Martinsburg, West Virginia
Posted · 25.09.2026
USAJOBS

# Registered Nurse - Home Telehealth Care Coordinator

Veterans Health Administration

Home Telehealth Care Coordinator (HTCC) Registered Nurse (RN) demonstrates leadership, experience, and creative approaches to management of complex patient care. The HTCC is responsible for coordination of health care for a defined patient population, identified as high resource users or at high risk for decline. Patients receive goal-oriented, coordinated care addressing holistic needs with the aim of preventing disease complications, maximizing functional ability, and quality of life.
This is an intermittent position within Connected Care. The functions and responsibilities of the HTCC include but is not limited to: Adhering to established policies, standards of care and standards of practice is consistent with the plan of other health care providers Coordinating and facilitating the provision of clinical and psychosocial services in a setting best suited to the services and to the healthcare needs of assigned patients. Implementing measures to improve access to care and the provision of timely health care interventions. Working collaboratively with the patient, family/significant other, and members of the interdisciplinary team to implement a plan of care across the continuum to meet each patients individual needs and maintain or improve quality of life. Promoting strategies that contribute to the effective and efficient use of Medical Center and VISN resources. Providing care for his/her panel of patients through tele-health technology engaging the patient in self-responsibility for healthcare agency (can you? will you?). Being accountable for patient care follow-up to meet established clinical guidelines/performance measures. Reviewing consults of patients to assign telehealth technology, coordinating follow-up care for patients across the continuum, and providing interventions to reduce hospitalizations and ER visits in collaboration with the Primary Care Team. Enhancing patient satisfaction and patient advocacy. Providing consultation to other health care providers, disciplines, and departments; e.g. Home Telehealth for optimizing blood glucose in diabetic patients. Teaching other members of the health care team regarding clinical, fiscal and system processes related to nursing case management with home telehealth technology. Providing data about indicators related to clinical and fiscal outcomes. Collecting, analyzing, and sharing of data and information in order to influence performance improvement goals. Providing leadership in the application of the nursing process to client care, organizational processes in order to improve outcomes at the program level. Serving as a liaison to the patient, his/her family, and members of the multidisciplinary team and hospital systems, to facilitate the management of patient-centered care" right care, right place, and right time. Adhering to appropriate interpersonal skills, working closely with all members of the interdisciplinary team. Assuming the role of educating staff to meet changing program or service needs and consulting regarding issues such as care planning, policy interpretation and others. Responsible for the documented outcomes at the program or service level. Program of service level outcomes must be broad and complex and can be demonstrated at any organizational level. 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 401K 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: Intermittent. Telework: Not Available. Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized. Permanent Change of Station (PCS): Not Authorized.
Basic Requirements: English Language Proficiency. In accordance with 38 U.S.C. 7403(f), no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English. Graduate of a school of professional nursing approved by the appropriate 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); OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program. Upon achievement of a State license, the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program. (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 to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program. Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD). 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. Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements, but do not possess the required licensure, may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.) NOTE: Grandfathering Provision
• All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification. Grade Determinations: The following Scope, Education and Dimension criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade. The Dimension requirements (Practice, Veteran/Patient Driven Care, Leadership, Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: https://apply.usastaffing.gov/ViewQuestionnaire/13072229. Grade/Level Scope Education Nurse I, Level I Delivers fundamental, knowledge-based care to assigned clients while developing technical competencies. An Associate Degree (ADN) or Diploma in Nursing, with no additional professional nursing required. Nurse I, Level II Demonstrates integration of biopsychosocial concepts, cognitive skills and technically competent practice in providing care to clients with basic or complex. An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I, Level 1 ;OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required. Nurse I, Level III Demonstrates proficiency in practice based on conscious and deliberate planning. Self-directed in goal setting for managing complex client situations. An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I, Level 2; OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I, Level 2; OR a Master's degree in nursing (MSN) and no additional professional nursing experience; OR a Master's degree in a related field with a BSN and no additional professional nursing experience. Nurse II Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others. A BSN with 2 years of professional nursing equivalent to Nurse I, Level 3; OR an MSN with one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Master's degree in a related field with a BSN and one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Doctoral degree in Nursing with no professional nursing experience; OR a Doctoral degree in a related field with a BSN with no additional professional nursing experience. Nurse III Executes position responsibilities that demonstrate leadership, experience and creative approaches to management of complex client care beyond the immediate practice setting. MSN and 2 years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Master's degree in related field with BSN and two years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in a related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III. Note: Foreign education programs/degrees are not creditable as related degrees. Preferred Experience: Case Management Experience within the last 5 years, Preferred Care Coordination/Patient Aligned Care Team/Primary Care Experience, Preferred Traumatic Brain Injury/Mental Health/Chronic Care Experience, Preferred Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service for requirements.
U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. Selective Service Registration is required for males born after 12/31/1959. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical evaluation, Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). You may be required to serve a probationary period. Complete all application requirements detailed in the "Required Documents" section of this announcement.

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