PACT Registered Nurse Care Manager

Summary

The Patient Aligned Care Team (PACT) Registered Nurse Care Manager (RNCM): Outpatient Primary Care (PC) delivers fundamental knowledge-based nursing care and care coordination within the Primary Care PACT. The PACT RNCM provides fundamental, knowledge-based, coordinated nursing care to panels of patients.

Duties

The PACT RNCM acts as the coordinator for a designated panel of patients, emphasizing health promotion, chronic care management, patient self-management support, and overall wellness. This role focuses on proactive, patient-centered care by using nursing knowledge, evidence-based guidelines, and standardized nursing procedures/protocols. 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. Demonstrates accountability, reliability, flexibility, teamwork, and adaptability in a fast-paced outpatient environment. 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 07:30am - 04:00pm. Subject to change based on the 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

Qualifications

Basic Requirements: English Language Proficiency. In accordance with 38 U.S.C. 7403(f), no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English. Graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE); OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program. Upon achievement of a State license, the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program. (Reference VA Handbook 5005, Appendix G6); OR In cases of graduates of foreign schools of professional nursing, possession of a current, full, active, and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program. Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD). Current, full, active, and unrestricted registration as a graduate professional nurse in a State, Territory or Commonwealth (i.e., Puerto Rico) of the United States, or the District of Columbia. Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements, but do not possess the required licensure, may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.) NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification. Grade Determinations: The following Scope, Education and Dimension criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade. The Dimension requirements (Practice, Veteran/Patient Driven Care, Leadership, Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: https://apply.usastaffing.gov/ViewQuestionnaire/13070069. Grade/Level Scope Education Nurse I, Level I Delivers fundamental, knowledge-based care to assigned clients while developing technical competencies. An Associate Degree (ADN) or Diploma in Nursing, with no additional professional nursing required. Nurse I, Level II Demonstrates integration of biopsychosocial concepts, cogniti