PACT Registered Nurse Care Manager

Department of Veterans Affairs

The Patient Aligned Care Team (PACT) Registered Nurse Care Manager (RNCM): Outpatient Primary Care (PC) demonstrates proficiency in practice providing nursing care and care coordination based on conscious and deliberate planning within the Primary Care PACT. NOTE: The 2-page Resume requirement does not apply to this position.

• Major Duties include, but are not limited to: Self-directed in functioning as a team member providing comprehensive, coordinated nursing care to panels of patients with occasional supervision. Focuses on proactive, patient-centered care by using nursing knowledge, evidence-based guidelines, and standardized nursing protocols. Manages care coordination for a designated panel of patients, emphasizing health promotion, chronic care management, patient self-management support, and overall wellness. Collaborate with the PACT members, extended care support team, and external services to develop and implement holistic, patient-driven care, facilitate care transitions, and provide timely, coordinated access to health care resources. Engages in patient and family education and advocates for patients' needs to enhance patient outcomes and wellness. Demonstrates a collaborative team approach for managing patient panels, ensuring continuity and quality of care tailored to individual patient goals and needs. Connects patients with wraparound services; coordinates care and ensures smooth transitions between acute and ambulatory settings for assigned patients with chronic disease, population health, post-discharge, or acute needs. Monitors assigned PACT metrics and uses VHA panel-management tools to identify care gaps, prepare patient data, and support proactive, high-quality primary care delivery. Identifies and manages assigned patients requiring RN care through daily huddles and team collaboration; develops individualized care, provides health coaching and motivational interviewing, and delivers ongoing management for patients with chronic and ambulatory care-sensitive conditions. Self-directed in providing primary care coordination for the Patient Aligned Care Team (PACT), overseeing transitions of care, developing and implementing Veteran-centered nursing care, delivering preventive and chronic disease management interventions, and providing care through multiple modalities, including face-to-face visits, virtual encounter. This position potentially requires flexibility in schedule and assignments. All 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 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: Monday-Friday, 0800-1630 Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

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