Registered Nurse - Patient Aligned Care Team Care Manager

PACT RN Care Manager

The VA Midwest Health Care Network advocates for a Whole Health System of care in each of the Medical Centers. This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest. As an employee operating in a Whole Health System of care, you will operate in a model with three core elements, seeking to create a personalized health plan for each Veteran.

This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community. This aligns with the Veterans Health Administration (VHA) Mission Statement to Honor America's Veterans by providing exceptional health care that improves their health and well-being. The primary duties for the PACT RN Care Manager position include, but are not limited to the following:

• Coordinate comprehensive nursing care for a designated panel of patients within the PACT, focusing on patient education, chronic disease management, self-management support, and prevention services across in-person and virtual modalities.
• Utilize population health tools and evidence-based guidelines to identify high-risk and chronically ill patients; engage in structured panel management to optimize health outcomes and support ongoing patient self-management.
• Serve as the primary point of contact for Veterans and families, providing proactive care management, care coordination, and ensuring timely access and transitions between primary, specialty, and extended care services.
• Conduct daily team huddles with PACT members to identify patients requiring RN care; deliver individualized interventions including health coaching, motivational interviewing, and ongoing management for chronic and ambulatory care-sensitive conditions.
• Apply clinical reminders, standing orders, and nurse protocols to deliver preventive health services, chronic disease management, and health coaching to achieve Veteran-centered care goals and improve outcomes within the practice setting.
• Coordinate same-day needs and post-discharge transitions by managing lab results, procedures, follow-ups, and referrals, ensuring Veterans are connected with appropriate internal and external resources.
• Identify care gaps using data-driven risk indicators and collaborate with interdisciplinary team members to prioritize and coordinate referrals for enhanced care management, focusing on high-risk and rising-risk patient populations.
• Promote patient-centered care and wellness by advocating for patient needs, facilitating Whole Health principles, and supporting patients and families in achieving optimal health outcomes.
• Monitor and report team metrics using VHA panel management tools, preparing patient data and supporting proactive, high-quality care planning and delivery to meet PACT goals in access, continuity, and quality.
• Demonstrate leadership in professional nursing practice, integrating evidence-based guidelines, participating in quality improvement initiatives, and ensuring compliance with the Nurse Practice Act and VA policies for safe, effective patient care.

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 through Friday

Telework:
Not Available

Virtual:
This is not a virtual position.

Relocation/Recruitment

Incentives:

Not Authorized

Permanent Change of Station (PCS):
Not Authorized