The PACT RNCM acts as the primary coordinator for a designated panel of patients emphasizing health promotion, chronic care management, patient self-management support, and overall wellness.
Care Coordination & Transition Management: 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.
Patient Care/Customer Service: 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.
Population Identification: 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.
Stratification, Care Coordination & Transition Management: 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.
Team Support and Teamwork: 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.
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: Monday - Friday; 8:00 a.m.
- 4:30 p.m. Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized
IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education. Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/.
If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html."
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $80018 – $149392/yr.
Applications close on 2026-10-26.
This is a Days, Monday-Friday: 8am-430pm position.
This position is open under the 'Public' hiring path.
Source: USAJOBS.gov — U.S. Federal Government · Retrieved 2026-10-23 · Not affiliated with or endorsed by OPM or USAJOBS.gov
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