Registered Nurse - (Patient Aligned Care Team Care Manager

Patient Aligned Care Team (PACT) Registered Nurse Care Manager (RNCM):
Outpatient Primary Care

The Patient Aligned Care Team (PACT) Registered Nurse Care Manager (RNCM) demonstrates expertise in professional nursing practice to provide nursing care and care coordination within the Primary Care PACT and improve outcomes beyond the immediate practice setting. The PACT RNCM functions as a key team member providing comprehensive, coordinated nursing care to panels of patients. This role leads proactive, patient-centered care by using nursing expertise, evidence-based guidelines, and standardized nursing protocols to improve outcomes within the immediate PACT and beyond.

The PACT RNCM acts as the primary coordinator for a designated panel of patients emphasizing health promotion, chronic care management, patient self-management support, and overall wellness. They collaborate with the PACT team members, extended care support team and external services to develop and implement holistic, patient-driven care, facilitate care transitions, and ensure timely, coordinated access to health care resources. The PACT RNCM also engages in patient and family education and advocates for patients' needs to enhance patient outcomes and wellness.

The PACT RNCM champions a collaborative team approach for managing patient panels, ensuring continuity and quality of care tailored to individual patient goals and needs with positive outcomes for patients, the immediate practice setting, and beyond the immediate practice setting. Nursing practice must be in accordance with the Nurse Practice Act of the State, Territory or Commonwealth of the United States, or the District of Columbia governing licensure.

Duties include but not limited too:

• Care Coordination & Transition Management
  • Provides expertise in 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 encounters, secure messaging, and telephone-based services.
  • Utilizes population health tools and evidence-based guidelines to identify and manage high-risk and chronically ill patients to improve quality of care and resource utilization at the expert level with improved outcomes beyond the immediate practice setting; collaborates with interdisciplinary team members, at the expert level, to apply structured appointment grids, and engage in proactive panel management to optimize health outcomes, support self-management, and reduce avoidable complications.
• Patient Care/Customer Service
  • Provides proactive, evidence-based care management using clinical reminders, policy orders/nurse protocols, and population health tools, delivering chronic disease management, preventive health services, patient education, and health coaching to support Veteran-centered goals across all stages of care. Leads initiatives to improve Veteran/patient experience.
  • Self-directed in coordinating same-day needs and post-discharge transitions by managing procedures, labs, follow-up, pre-visit preparation, clinical reminders, and referrals; ensures Veterans are connected with appropriate services, specialty care, and interdisciplinary team resources.
  • Demonstrates expertise in identifying and managing 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 resulting in improved evidence-based and/or data-driven outcomes beyond the immediate practice setting.

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:

Full Time,  (extended hours as needed, schedule subject to change based on agency needs.) Telework:
Not Available Virtual:
This is not a virtual position. Permanent Change of Station (PCS):
Not Authorized