Registered Nurse - Patient Aligned Care Team (PACT) Care Manager

Veterans Health Administration • Fargo, ND

5h • Onsite

About The Position

The Patient Aligned Care Team (PACT) Registered Nurse (RN) Care Manager uses the nursing process and evidence-based practice to deliver and manage comprehensive care for an assigned panel of patients in a clinic setting. The RN is a key member of the PACT and multidisciplinary team, collaborating with other team members and promoting effective communication and ethical practice.

The role supports the VA Midwest Health Care Network’s Whole Health System of care, which empowers Veterans to take charge of their health and well-being. Care is organized around personalized health plans, healing relationships and environments, and connections to the Veteran’s community. This approach aligns with the Veterans Health Administration mission to honor America’s Veterans by providing exceptional health care that improves their health and well-being.

The position works Monday through Friday, 8:00 a.m. to 4:30 p.m. Telework is not available, and this is not a virtual position. Relocation and recruitment incentives and permanent change of station are not authorized.

Requirements

• Proficiency in basic written and spoken English.
• Graduation from an appropriately accredited school of professional nursing, or qualifying education under the stated VA provisions for bridge-program candidates or graduates of foreign nursing schools.
• Current, full, active, and unrestricted registered professional nurse licensure in a U.S. state, territory, commonwealth, or the District of Columbia, subject to the Graduate Nurse Technician exception described in the posting.
• Meet the education and professional nursing experience criteria for the applicable Nurse grade and level.
• Satisfy VA employment conditions, including U.S. citizenship subject to the stated exception, applicable Selective Service registration, background/security investigation, pre-employment drug screening for testing-designated positions, and pre-employment physical evaluation.
• Participate in the seasonal influenza vaccination program and complete required onboarding and application requirements.

Nice To Haves

• Experience in Primary Care or an outpatient clinical area.

Responsibilities

• Serve as the primary point of contact for care management and coordination for an assigned patient panel, focusing on high-risk patients, care transitions, and population health strategies using data resources.
• Develop, implement, and update individualized, patient-driven care plans in collaboration with interdisciplinary teams and patients or families, using nursing expertise, evidence-based guidelines, and standardized protocols.
• Provide health education, coaching, and counseling to patients and families, emphasizing self-management, prevention, wellness, and shared decision-making.
• Work with the PACT team, internal and external VA services, and community-based resources to assess patient needs, support care transitions, and ensure comprehensive patient care.
• Participate in performance improvement activities, use patient registries and data resources for population health management, and monitor outcomes to identify care gaps and improve patient wellness.
• Maintain current knowledge of multidisciplinary resources and programs, refer patients as appropriate, and help them navigate the healthcare system and its processes.
• Assess patients for telehealth and home monitoring devices and use VA Video Connect.
• Document patient interactions and interventions in the patient record, complete encounters for workload credit, and support compliance with standards and nursing practice aligned with Primary Care ICC and CAN Score management.

Benefits

• Competitive salary, regular salary increases, and potential performance awards.
• 50 days of paid time off per year: 26 days annual leave, 13 days sick leave, and 11 paid federal holidays.
• Traditional federal pension with five-year vesting and federal 401(k) with up to 5% in contributions by VA.
• Federal health, vision, dental, term life, and long-term care insurance; many federal insurance programs can be carried into retirement.
• Licensure benefit: one full and unrestricted license from any U.S. state or territory.

What This Job Offers

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