Registered Nurse - Patient Aligned Care Team Care Manager

Job Title

Duties

Duties include 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.
• 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.
• 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.
• 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.

VA offers a comprehensive total rewards package:

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:

8:00am-4:30pm, Monday - Friday, subject to change based on needs of the facility

Telework:
Not Available

Virtual:
This is not a virtual position.

Relocation/Recruitment

Incentives:

Not Authorized

Permanent Change of Station (PCS):
Not Authorized

PCS Appraised Value Offer (AVO):
Not Authorized