The Nurse Patient Aligned Care Team (PACT) Outpatient Staff Registered Nurse (RN) is responsible and accountable for all elements of the nursing process when providing nursing care and care coordination within the Primary Care PACT. The role demonstrates leadership in delivering proactive, patient-centered care by using knowledge, evidence-based guidelines, and standardized nursing protocols within the immediate practice setting.
*** Recruitment or Relocation incentive authorized for eligible, highly qualified candidates! *** Duties include but are not limited to: Collaborates with the PACT members, extended care support team, and external services to develop and implement holistic, patient-driven care, facilitate care transitions, and ensure timely, coordinated access to health care resources.
Engages in patient and family education and advocates for patients' needs to enhance patient outcomes and wellness. 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; 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.
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. Communicates and treats customers (patients, visitors, volunteers, and all Medical Center staff) in a courteous, tactful, and respectful manner.
Provides the customers with consistent information according to established policies and procedures. Handles conflict and problems in dealing with the customer constructively and appropriately. Assesses data reflective of the patient's status and interpret the information needed to identify each patient's requirements relative to their age- specific needs and to provide care needed as described in the services' policies and procedures.
Identifies and manages patients requiring RN care through daily huddles and team collaboration; individualized care, health coaching and motivational interviewing, and delivers ongoing management for patients with chronic and ambulatory care sensitive conditions. Monitors team metrics and uses VHA panel management tools to identify care gaps, prepare patient data, and support proactive, high-quality primary 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: 8:00am - 4:30pm, Monday through Friday with occasional evenings and weekends to accommodate extended hours.
Compressed/Flexible: Not Authorized Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized
chandijo.brooks@va.gov · 716-207-6823
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $81491 – $143608/yr.
Applications close on 2026-08-31.
This position is open under the 'Fed Internal Search' hiring path.
Source: USAJOBS.gov — U.S. Federal Government
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