Registered Nurse - Patient Aligned Care Team Care Manager

Job description

Patient Aligned Care Team (PACT) Registered Nurse Care Manager (RNCM): Outpatient Primary Care

The Patient Aligned Care Team (PACT) Registered Nurse Care Manager (RNCM): Outpatient Primary Care manages care coordination for a designated panel of patients, emphasizing health promotion, chronic care management, patient self-management support, and overall wellness. They collaborate with the PACT members, extended care support team, and external services to develop and implement holistic, patient-driven care, facilitate care transitions, and provide timely, coordinated access to health care resources.

Major duties include but are not limited to:

Self-directed in providing 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 with occasional supervision.

Applies 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.

Identifies and manages assigned patients requiring RN care through daily huddles and team collaboration; develops individualized care, provides health coaching and motivational interviewing, and delivers ongoing management for patients with chronic and ambulatory care-sensitive conditions.

Uses data-driven risk indicators to identify rising- and high-risk patients, prioritize focused panel management, and coordinate appropriate referrals for enhanced care management.

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 improved clinical outcomes.

Monitors assigned PACT 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

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 8:00AM to 4:30PM

Telework: Not Available

Virtual: This is not a virtual position.

Relocation/Recruitment Incentives: Not Authorized

Permanent Change of Station (PCS): Not Authorized

The VA Midwest Health Care Network advocates for a Whole Health System of care in each of the Medical Centers. This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest. As an employee operating in a Whole Health System of care, you will operate in a model with three core elements, seeking to create a personalized health plan for each Veteran. This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community. This aligns with the Veterans Health Administration (VHA) Mission Statement to Honor America's Veterans by providing exceptional health care that improves their health and well-being.

Who can apply

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