Registered Nurse - Patient Aligned Care Team Care Manager (IMC & GEM Clinic Float)

The Patient Aligned Care Team (PACT) Registered Nurse Care Manager (RNCM): Outpatient Primary Care (PC) is responsible and accountable for all elements of the nursing process when providing nursing care and care coordination within the Primary Care PACT. The PACT RNCM assumes responsibility for the coordination of care focused on patient education, self-management, and customer satisfaction while functioning as a key team member providing comprehensive, coordinated nursing care to patients.

Major Duties: Serves as the primary care coordinator for a designated panel of patients within the Patient Aligned Care Team (PACT), providing comprehensive, patient-centered nursing care and care coordination. Accountable for all elements of the nursing process, emphasizing patient education, self-management, health promotion, chronic disease management, wellness, and customer satisfaction. Leads proactive, evidence-based nursing practice by applying clinical guidelines, nursing protocols, quality improvement principles, and population health strategies to improve patient outcomes. Coordinates and manages transitions of care across inpatient, outpatient, specialty, and community settings, ensuring timely access to appropriate healthcare resources and services. Provides care through multiple modalities, including face-to-face visits, virtual care, telephone encounters, and secure messaging. Uses population health tools, risk stratification, and panel management techniques to identify high-risk patients, close care gaps, prevent complications, and improve health outcomes. Delivers RN-led chronic disease management, preventive care, health coaching, motivational interviewing, and individualized care planning to support patient goals and self-management. Coordinates same-day care needs, post-discharge follow-up, referrals, laboratory and diagnostic testing, clinical reminders, procedures, and pre-visit planning. Collaborates with interdisciplinary team members, extended care support teams, patients, families, and community resources to develop and implement holistic, Veteran-centered care plans. Advocates for patients and families through education, support, and facilitation of services that promote continuity of care, wellness, and improved outcomes. Participates in daily huddles, pre-planning activities, and ongoing team communication to support access, continuity, quality, patient experience, and efficient clinic operations. Applies Whole Health principles and appropriate task delegation to strengthen team performance, care coordination, and achievement of PACT goals. Monitors performance metrics and utilizes VHA panel management tools to identify care gaps, support data-driven decision-making, and improve quality outcomes. Demonstrates leadership in professional nursing practice through evidence-based care, collaborative teamwork, resource management, and continuous quality improvement. Practices in accordance with applicable Nurse Practice Acts and licensure requirements governing professional nursing practice. 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, 7:30am-4:00pm Telework: Ad-Hoc Only. 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. 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.