Registered Nurse-Outpatient Primary Care

Department of Veterans Affairs

The Patient Aligned Care Team (PACT) Registered Nurse (RN) Care Manager will utilize the nursing process, evidence-based practice, and metrics to deliver and manage comprehensive care to an assigned panel of patients in a clinic setting. The RN is a key member of the PACT and multidisciplinary team and is responsible for collaboration with other team members, promoting effective communication and ethical practice while integrating population health to meet the needs of the Veteran.

• Duties include but are not limited to: The RN PACT Care Manager is responsible for providing competent, evidence-based care to assigned patients. Provides patient management, care coordination, and discharge planning for inpatient and outpatient settings, assisting Veterans, family members, and caregivers in accessing appropriate services for complex health care needs. The RN PACT care Manager coordinates care across multiple providers and settings, ensuring continuity of care within VA and community programs. Integrates nursing protocols in daily practice to work to the top of education and competency Applies clinical knowledge/judgment to lead staff involvement in planning, decision-making, and evaluating outcomes within the immediate practice setting Effectively functions as a leader, with demonstrated outcomes, for the immediate practice setting Improves Veteran/patient driven care by resolving experience issues such as coordination of care, timeliness or process issues, common themes of dissatisfaction, or environment of care concerns for the immediate practice setting Serves as a resource and advocate for patients, families, and caregivers, improving outcomes for the immediate practice setting Demonstrates the ability to improve the effectiveness of communications and interactions with others, to inspire their cooperation and confidence to ensure safe and effective outcomes in the current practice setting Leads teams, contributes to team huddles, and actively collaborates in all phases of patient care planning; reviews team metrics and assist team in developing a plan to improve patient outcomes Integrates population health into daily practice with RN nurse visits, using patient-centered needs and goals, assessment, and metrics while using motivational interviewing to improve Veteran wellness and outcomes Complete two-day discharge calls, coordinate discharge follow-up from the hospital, Emergency Department (ED), or other setting Provide patient and family health education with a focus on self-management, shared decision making, and prevention and wellness that is based on the individual patient's goals Recognizes and triages urgent or emergent patient care situations and initiates appropriate emergency interventions as directed Participates in team performance improvement and sustainment activities to optimize team efficiency and care delivery to patients Perform virtual care modality visits (VVC, CVT) 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- 0700-1530 or 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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