Registered Nurse - PACT Care Manager

The Registered Nurse Care Manager will focus on proactive, patient-centered care by using nursing knowledge, evidence-based guidelines, and standardized nursing procedures/protocols.

https://youtu.be/EGW4PMZvJto?si=_f7pNchVqoK1KZal Duties and responsibilities include, but are not limited to, the following: Provide fundamental primary care coordination for the PACT, supporting transition of care, collaborating in Veteran-centered nursing care, deliver preventative and chronic disease management interventions, and provide fundamental care through multiple modaltities, including face-to-face visits, virtual encounters, secure messaging, and telephone-based services. Aware of population health tools and knowledge of evidence-based guidelines to identify and manage high-risk and chronically ill patients; serve on the interdisciplinary team, apply structured appointment grids, and engage 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 order/nurse protocols, and population health tools, and the ability to deliver fundamental chonic disease management, preventitive health services, patient education, and health coaching to support Veteran-centered goals. Collaborate in the coordination of same-day needs and post-discharge transitions by completing procedures, labs, follow-up, pre-visit preparation, clinical reminders, and referrals; work to connect Veterans with appropriate services, specialty care, and interdisciplinary team resources. Participate in daily huddles and collaborate with others to manage patients requiring RN care; provide individualized care, health coaching, motivational interviewing, and ongoing management for patients with chronic and ambulatory care-sensitive conditions. Knowledge of date-driven risk indicators to identify rising and high-risk patients and awareness of focused panel management prioritization and referral coordination for care management. Connect patients with wraparound services; participate 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. Collaborate 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. 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, 8's or 9's Compressed/Flexible: Available Telework: This position is authorized for telework - situational (ad hoc) and has NOT been authorized as virtual or remote. Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. Selective Service Registration is required for males born after 12/31/1959. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical evaluation/examination. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). You may be required to serve a probationary period. Complete all application requirements detailed in the "Required Documents" section of this announcement.