Registered Nurse - Patient Aligned Care Team Care Manager (IMC & GEM Clinic Float)

Veterans Health Administration • San Antonio, TX

20h • 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 and for coordinating patient care within the Primary Care PACT. The RNCM manages a designated patient panel and provides comprehensive, patient-centered nursing care, coordinating services with an emphasis on patient education, self-management, health promotion, chronic disease management, wellness, and customer satisfaction.

The RNCM uses evidence-based nursing practice, clinical guidelines, nursing protocols, quality-improvement principles, population-health strategies, risk stratification, and panel-management tools to identify care gaps, support data-driven decisions, and improve patient outcomes. Care is delivered through face-to-face visits, virtual care, telephone encounters, and secure messaging. The role coordinates transitions across inpatient, outpatient, specialty, and community settings, as well as same-day needs, post-discharge follow-up, referrals, testing, clinical reminders, procedures, and pre-visit planning.

The nurse collaborates with interdisciplinary teams, patients, families, extended-care support teams, and community resources to develop holistic, Veteran-centered care plans. The RNCM participates in huddles and team planning, applies Whole Health principles, delegates tasks appropriately, and contributes leadership, resource management, and continuous quality improvement. The position is a permanent, non-virtual role with ad-hoc telework only and a Monday–Friday schedule from 7:30 a.m. to 4:00 p.m.

Requirements

• Proficiency in basic written and spoken English.
• Graduation from an appropriately accredited school of professional nursing (ACEN or CCNE), or an applicable qualifying nursing education pathway described in the posting.
• Current, full, active, and unrestricted registered nurse license in a U.S. state, territory, commonwealth, or the District of Columbia; a temporary Graduate Nurse Technician appointment may be available to otherwise qualified candidates pursuing licensure.
• Meet the education and experience criteria for the assigned VA Nurse grade and level; these vary by grade and may include an ADN/diploma, BSN, MSN, doctoral degree, and specified professional or specialized nursing experience.
• Submit transcripts when education is used to meet qualification requirements; foreign education requires applicable equivalency documentation.
• U.S. citizenship, except where VA policy permits appointment of non-citizens when qualified citizens cannot be recruited.
• Complete required pre-employment screening and onboarding, including applicable drug testing, background/security investigation, identification requirements, and seasonal influenza vaccination requirements.
• Register for Selective Service if applicable to males born after December 31, 1959.
• Complete application requirements described in the announcement’s Required Documents section.

Nice To Haves

• Three years of nursing experience.
• Bachelor of Science in Nursing (BSN).
• Primary Care/PACT experience.
• Triage or telephone triage experience.
• BLS certification (listed as required under Preferred Experience).

Responsibilities

• Coordinate comprehensive, patient-centered nursing care for a designated panel of PACT patients.
• Provide all elements of the nursing process, including patient education, self-management support, health promotion, chronic disease management, wellness, and customer-satisfaction efforts.
• Apply clinical guidelines, nursing protocols, evidence-based practice, quality-improvement principles, and population-health strategies to improve outcomes.
• Coordinate transitions of care across inpatient, outpatient, specialty, and community settings and facilitate access to appropriate resources and services.
• Provide care through in-person visits, virtual care, telephone encounters, and secure messaging.
• Use population-health tools, risk stratification, and panel management to identify high-risk patients, close care gaps, prevent complications, and improve outcomes.
• Deliver RN-led chronic disease management, preventive care, health coaching, motivational interviewing, and individualized care planning.
• Coordinate same-day care needs, post-discharge follow-up, referrals, laboratory and diagnostic testing, clinical reminders, procedures, and pre-visit planning.
• Collaborate with interdisciplinary teams, extended-care support teams, patients, families, and community resources to develop and implement Veteran-centered care plans.
• Advocate for patients and families through education, support, and facilitation of services that promote continuity, wellness, and improved outcomes.
• Participate in daily huddles, pre-planning, and ongoing team communication to support access, continuity, quality, patient experience, and efficient clinic operations.
• Apply Whole Health principles and delegate tasks appropriately to strengthen team performance, care coordination, and achievement of PACT goals.
• Monitor performance metrics and use VHA panel-management tools to identify care gaps, inform decisions, and improve quality outcomes.
• Demonstrate leadership through evidence-based nursing practice, collaborative teamwork, resource management, and continuous quality improvement.
• Practice in accordance with applicable Nurse Practice Acts and professional nursing licensure requirements.

Benefits

• Competitive salary, regular salary increases, and potential performance awards.
• 50 days of paid time off per year: 26 days of annual leave, 13 days of sick leave, and 11 paid federal holidays.
• Traditional federal pension with five-year vesting.
• 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.

What This Job Offers

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