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Job description
Job Title
Responsibilities include, but are not limited to the following:
Provides primary care coordination for the Patient Aligned Care Team (PACT), overseeing transitions of care, developing and implementing Veteran-centered nursing care, delivering preventive and chronic disease management interventions, and providing care through multiple modalities, including face-to-face visits, virtual encounters, secure messaging, and telephone-based services.
Utilizes population health tools and evidence-based guidelines to identify and manage high-risk and chronically ill patients; collaborates with interdisciplinary team members, applies structured appointment grids, and engages in panel management to optimize health outcomes, support self-management, and reduce avoidable complications.
Provides proactive, evidence-based care management using clinical reminders, policy orders/nurse protocols, and population-health tools, delivering chronic disease management, preventive health services, patient education, and health coaching to support Veteran-centered goals across all stages of care and improve outcomes for the immediate practice setting.
Coordinates same-day needs and post-discharge transitions by managing procedures, labs, follow-up, pre-visit preparation, clinical reminders, and referrals; ensures Veterans are connected with appropriate services, specialty care, and interdisciplinary team resources.
Identifies and manages patients requiring RN care through daily huddles and team collaboration; individualized care, health coaching and motivational interviewing, and delivers ongoing management for patients with chronic and ambulatory care sensitive conditions.
Delivers ongoing RN led chronic disease management using Veterans Affairs/Department of Defense (VA/DOD) clinical guidelines, evidence-based guidelines, health coaching, and collaboration with extended team members to support patient self-management, goal setting, and optimized 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
Applies Whole Health principles and appropriate task delegation to strengthen team functioning, enhance care coordination, and meet PACT performance goals.
Monitors team metrics and uses 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
Competitive salary, regular salary increases, potential for performance awards
50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year)
Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA
Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)
1 full and unrestricted license from any US State or territory
M-F- 7:00AM- 3:30PM
Not Available
Not Available
This is not a virtual position.
Not Authorized
Not Authorized
Worksite address
altoona, PA, 16603, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.