Registered Nurse (Patient Aligned Care Team Manager)

Veterans Health Administration • Syracuse, NY

5d • Onsite

About The Position

The Patient Aligned Care Team (PACT) Registered Nurse Care Manager (RNCM) in Outpatient Primary Care is responsible and accountable for all elements of the nursing process within the Primary Care PACT. The PACT RNCM focuses on care coordination, patient education, self-management, and customer satisfaction. This role involves utilizing population health tools, evidence-based guidelines, and structured appointment grids for proactive panel management to optimize health outcomes and reduce complications. The RNCM provides chronic disease management, preventive health services, patient education, and health coaching, while also coordinating same-day needs and post-discharge transitions. They identify and manage patients requiring RN care, develop individualized care plans, and deliver ongoing management for patients with chronic and ambulatory care-sensitive conditions. The role also includes leading initiatives to identify rising and high-risk patients, coordinating referrals, and improving processes or patient outcomes. Collaboration with PACT core team members and the extended care support team is essential for achieving PACT goals related to access, continuity, patient experience, and quality outcomes. The RNCM applies Whole Health principles and appropriate task delegation to strengthen team functioning and enhance care coordination.

Requirements

• U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment.
• Applicants who refuse to be tested will be denied employment with VA.
• Selective Service Registration is required for males born after 12/31/1959.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process.
• Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents).
• Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Must pass pre-employment physical examination.
• 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.
• English Language Proficiency. In accordance with 38 U.S.C. 7403(f), no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English.
• Graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE); OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program. Upon achievement of a State license, the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program. (Reference VA Handbook 5005, Appendix G6); OR In cases of graduates of foreign schools of professional nursing, possession of a current, full, active, and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program. Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD).
• 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.
• Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements, but do not possess the required licensure, may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.)
• Long periods of continued walking, standing, sitting, moderate lifting, repeated bending, or kneeling.

Nice To Haves

• An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I, Level 1 ; OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required.
• An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I, Level 2; OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I, Level 2; OR a Master's degree in nursing (MSN) and no additional professional nursing experience; OR a Master's degree in a related field with a BSN and no additional professional nursing experience.
• A BSN with 2 years of professional nursing equivalent to Nurse I, Level 3; OR an MSN with one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Master's degree in a related field with a BSN and one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Doctoral degree in Nursing with no professional nursing experience; OR a Doctoral degree in a related field with a BSN with no additional professional nursing experience.
• MSN and 2 years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Master's degree in related field with BSN and two years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in a related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III.

Responsibilities

• Provides expertise in 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 to improve quality of care and resource utilization at the expert level with improved outcomes beyond the immediate practice setting; collaborates with interdisciplinary team members, at the expert level, to apply structured appointment grids, and engage in proactive 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.
• Leads initiatives to improve Veteran/patient experience.
• 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.
• Demonstrates expertise in identifying and managing 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 resulting in improved evidence-based and/or data-driven outcomes beyond the immediate practice setting.
• Leads initiatives to improve data driven outcomes by using data-driven risk indicators to identify rising- and high-risk patients, prioritize focused panel management, and coordinate appropriate referrals for enhanced care management sharing best practices/improvements beyond the immediate practice setting.
• Uses nursing expertise to identify gaps in care and connect patients with wraparound services; coordinates care and ensures smooth transitions between acute and ambulatory settings for patients with chronic disease, population health, post discharge or acute needs.
• Leads process improvement or quality improvement initiatives to improve processes or patient outcomes beyond the immediate practice setting.
• 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, pre-planning, 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, improve patient data, and lead proactive, high-quality primary care delivery with positive impact beyond the immediate practice setting.

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) 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

What This Job Offers

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