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Job description
PACT RN Care Manager
The primary duties for the PACT RN Care Manager include, but are not limited to:
Serve as the primary point of contact for care management and coordination for an assigned patient panel, focusing on high-risk patients, care transitions, and population health strategies utilizing data resources.
Use nursing expertise, evidence-based guidelines, and standardized protocols to develop, implement, and update individualized, patient-driven care plans in collaboration with interdisciplinary teams and patients/families.
Provide health education, coaching, and counseling to patients and families, emphasizing self-management, prevention, wellness, and shared decision-making.
Work actively with the PACT Team, internal and external VA services, and community-based resources to assess patient needs, support care transitions, and ensure comprehensive patient care.
Participate in performance improvement activities, utilize patient registries and data resources for population health management, and monitor outcomes to identify care gaps and enhance patient wellness.
Maintain current knowledge of multidisciplinary resources and programs, refer patients as appropriate, and serve as a resource for navigating the healthcare system and processes.
Assess patients for telehealth and home monitoring devices, utilize VA Video Connect, document all patient interactions and interventions in the patient record, complete encounters for workload credit, and support compliance with standards and nursing practice aligned with Primary Care ICC and CAN Score management.
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, multiple tours available
Compressed/Flexible: May be available
Telework: Not available
Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not authorized
EDRP: Position(s) listed under this Open Continuous Announcement (OCA) MAY be eligible for the Education Debt Reduction Program (EDRP), a student loan payment reimbursement program. Applicants selected for an EDRP-eligible position will be notified in their conditional job offer. The selectee must meet specific eligibility requirements per VHA policy and submit an EDRP application within four months of appointment. Program approval, award amount (up to $200,000), and eligibility period (one to five years) are determined by the VHA Education Loan Repayment Services program office after review of the EDRP application. Former EDRP participants are ineligible to apply.
Permanent Change of Station (PCS): Not authorized
PCS Appraised Value Offer (AVO): Not authorized
Worksite address
decatur, GA, 30089, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.