Registered Nurse- Primary Care- Care Manager

Department of Veterans Affairs

This position is eligible for the Education Debt Reduction Program (EDRP), a student loan payment reimbursement program. You must meet specific eligibility requirements per VHA policy and submit your EDRP application within four months of appointment. Program Approval, award amount (up to $200,000) & eligibility period (one to five years) are determined by the VHA Education Loan Repayment Services program office after review of the EDRP application. Former EDRP participants ineligible to apply.

• This Registered Nurse- Primary Care- Care Manager is located in the Nursing, Outpatient Primary Service at the Manchester VA location. This position is full-time at 40 hours per week. Duties are Included but are not limited to: Provides fundamental primary care coordination for the PACT, supporting transitions of care, collaborating in Veteran-centered nursing care, delivering preventive and chronic disease management interventions, and providing fundamental care through multiple modalities, including face-to-face visits, virtual encounters, secure messaging, and telephone-based services. Awareness of population health tools and knowledge of evidence-based guidelines to identify and manage high-risk and chronically ill patients; serves on the interdisciplinary team, applies structured appointment grids, and engages in proactive panel management to optimize health outcomes, support self-management, and reduce avoidable complications. Knowledge of proactive, evidence-based care management using clinical reminders, policy orders/nurse protocols, and population health tools, and the ability to deliver fundamental chronic disease management, preventive health services, patient education, and health coaching to support Veteran-centered goals. Collaborates in the coordination of same-day needs and post-discharge transitions by completing procedures, labs, follow-up, pre-visit preparation, clinical reminders, and referrals; works to connect Veterans with appropriate services, specialty care, and interdisciplinary team resources. Participates in daily huddles and collaborates with others to manage patients requiring RN care; provides individualized care, health coaching and motivational interviewing, and ongoing management for patients with chronic and ambulatory care-sensitive conditions. Knowledge of data-driven risk indicators to identify rising and high-risk patients and awareness of focused panel management prioritization and referral coordination for care management. Connects patients with wraparound services; participates in the coordination of care to provide smooth transitions between acute and ambulatory settings for patients with chronic disease, population health, post-discharge, or acute needs. Delivers ongoing, fundamental RN-led chronic disease management using Veterans Affairs/Department of Defense (VA/DOD) clinical practice guidelines, evidence-based guidelines, health coaching, and collaboration with extended team members to support patient self-management, goal setting, and improved clinical outcomes. Collaborates with PACT core team members and the extended care support team to reach PACT goals related to access, continuity, patient experience, and quality outcomes through huddles, preplanning, and daily communication to support access, continuity, quality, and patient experience while facilitating efficient, patient-ready visits. Awareness of Whole Health principles and appropriate task delegation to strengthen team functioning, enhance care coordination, and meet PACT performance goals. Knowledge of team metrics and VHA panel management tools to identify care gaps, prepare patient data, and support proactive, high-quality primary care delivery. Work Schedule: Full-Time, Monday-Friday 7:30 A.M- 4:00 P.M or 8:00 A.M to 4:30 P.M. Telework: Not Available. Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized. EDRP Authorized: Former EDRP participants ineligible to apply for incentive. Contact Hannah.Neilson@va.gov, the EDRP Coordinator for questions/assistance. Learn more. Permanent Change of Station (PCS): Not Authorized. Notifications: This is not a Bargaining Unit Position This position is in the Excepted Service This position is covered by a special rate. Current and former Federal employees must submit copies of their most recent SF-50, (Notice of Personnel Action). The SF-50 must identify the position title, series, grade, step, tenure and type of service (Competitive or Excepted). In some cases, more than one SF-50 may be required to show a higher grade previously held. 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. VA offers a comprehensive total rewards package: VA Nurse Total Rewards

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