Registered Nurse - PACT Care Manager

Department of Veterans Affairs

The Registered Nurse Care Manager will provide fundamental, knowledge based, coordinated nursing care to panels of patients.

• 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 transitions of care, collaborating in Veteran-centered nursing care, deliver preventive and chronic disease management interventions, and provide fundamental care through multiple modalities, 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 structure 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 orders/nurse protocols, and population health tools, and the ability to deliver fundamental chronic disease management, preventive 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 and motivational interviewing, and ongoing management for patients with chronic and ambulatory care-sensitive conditions. Knowledge of data-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 coordination of care to provide smooth transitions between acute and ambulatory settings for patients with chronic disease, population health, post-discharge, or acute needs. Deliver ongoing, fundamental RN-led chronic disease management using Veterans Affairs/Department of Defense (VA/DOD) clinical practice guidelines, evidence-based guidelines, health coaching, and collaboration with extended team members to support patient self-management, goal setting, and improved clinical outcomes. 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. Aware 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 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, 8:00am-4:30pm, M-F 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

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