PACT Registered Nurse Care Manager

Veterans Health Administration • Slidell, LA

6d • Onsite

About The Position

The Patient Aligned Care Team (PACT) Registered Nurse Care Manager (RNCM): Outpatient Primary Care (PC) delivers fundamental knowledge-based nursing care and care coordination within the Primary Care PACT. The PACT RNCM provides fundamental, knowledge-based, coordinated nursing care to panels of patients. This role focuses on proactive, patient-centered care by using nursing knowledge, evidence-based guidelines, and standardized nursing procedures/protocols. Provides fundamental primary care coordination for the PACT, supporting transitions of care, collaborating in Veteran-centered nursing care, delivering preventive and chronic disease management interventions, and providing fundamental care through multiple modalities, including face-to-face visits, virtual encounters, secure messaging, and telephone-based services. Awareness of population health tools and knowledge of evidence-based guidelines to identify and manage high-risk and chronically ill patients; serves on the interdisciplinary team, applies structured appointment grids, and engages 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. Collaborates in the coordination of same-day needs and post-discharge transitions by completing procedures, labs, follow-up, pre-visit preparation, clinical reminders, and referrals; works to connect Veterans with appropriate services, specialty care, and interdisciplinary team resources. Participates in daily huddles and collaborates with others to manage patients requiring RN care; provides 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. Connects patients with wraparound services; participates in the coordination of care to provide smooth transitions between acute and ambulatory settings for patients with chronic disease, population health, post-discharge, or acute needs. Delivers 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. 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. Awareness 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 primary care delivery. Demonstrates accountability, reliability, flexibility, teamwork, and adaptability in a fast-paced outpatient environment.

Requirements

• U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• Must be proficient in basic written and spoken English.
• Graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited by either The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE).
• Current, full, active, and unrestricted registration as a graduate professional nurse in a State, Territory or Commonwealth (i.e., Puerto Rico) of the United States, or the District of Columbia.
• Selected applicants will be required to complete an online onboarding process.
• Acceptable form(s) of identification will be required to complete pre-employment requirements.
• Must pass pre-employment physical evaluation.
• 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.

Nice To Haves

• Outpatient Ambulatory Care PACT RN Care Manager experience.
• Strong ambulatory/primary care nursing experience, preferably within PACT or a similar patient-centered medical home model.
• Demonstrated care coordination and case management skills, including hypertension, diabetes, preventive care, and HEDIS/eQM quality measures.
• Strong clinical assessment, triage, and critical-thinking skills with appropriate escalation of changes in condition.
• Effective interdisciplinary collaboration with providers, LPNs, MSAs, pharmacy, social work, and specialty services.
• Demonstrated ability to prioritize workload and independently manage a patient panel, including secure messages, alerts, follow-up, and care coordination.
• Experience utilizing virtual care modalities such as VVC, telephone care, and remote patient monitoring.
• Proficient with electronic health records and clinical documentation, preferably VA systems.
• BSN preferred.
• Applicable ambulatory care, case management, or nursing specialty certification desirable.

Responsibilities

• Acts as the coordinator for a designated panel of patients, emphasizing health promotion, chronic care management, patient self-management support, and overall wellness.
• Provides fundamental primary care coordination for the PACT, supporting transitions of care, collaborating in Veteran-centered nursing care, delivering preventive and chronic disease management interventions, and providing fundamental care through multiple modalities.
• Identifies and manages high-risk and chronically ill patients using population health tools and evidence-based guidelines.
• Serves on the interdisciplinary team and engages in proactive panel management to optimize health outcomes, support self-management, and reduce avoidable complications.
• Delivers fundamental chronic disease management, preventive health services, patient education, and health coaching to support Veteran-centered goals.
• Collaborates in the coordination of same-day needs and post-discharge transitions by completing procedures, labs, follow-up, pre-visit preparation, clinical reminders, and referrals.
• Connects Veterans with appropriate services, specialty care, and interdisciplinary team resources.
• Participates in daily huddles and collaborates with others to manage patients requiring RN care.
• Provides individualized care, health coaching and motivational interviewing, and ongoing management for patients with chronic and ambulatory care-sensitive conditions.
• Identifies rising and high-risk patients using data-driven risk indicators and participates in referral coordination for care management.
• Connects patients with wraparound services and coordinates care for smooth transitions between acute and ambulatory settings.
• Delivers ongoing, fundamental RN-led chronic disease management using VA/DOD clinical practice guidelines and evidence-based guidelines.
• 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.
• Facilitates efficient, patient-ready visits through communication and preplanning.
• Utilizes Whole Health principles and appropriate task delegation to strengthen team functioning, enhance care coordination, and meet PACT performance goals.
• Uses team metrics and VHA panel management tools to identify care gaps, prepare patient data, and support proactive, high-quality primary care delivery.
• Demonstrates accountability, reliability, flexibility, teamwork, and adaptability in a fast-paced outpatient environment.

Benefits

• 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)
• Federal 401K with up to 5% in contributions by VA
• Federal health/vision/dental/term life/long-term care insurance (many federal insurance programs can be carried into retirement)

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree