The Patient Aligned Care Team (PACT) Registered Nurse Care Manager (RNCM) provides 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.
https://youtube.com/embed/xIJUwRGeQi8 The PACT RN Outpatient Primary Care (PC) is responsible and accountable for all elements of the nursing process when providing nursing care and care coordination within the Primary Care PACT.
Duties of the position are, but not limited to: Coordination of care focused on patient education, self-management, and customer satisfaction while functioning as a key team member to provide comprehensive, coordinated nursing care to panels of patients. Proactive, patient-centered care by using nursing knowledge, evidence-based guidelines, and standardized nursing protocols within the immediate practice setting.
Primary coordinator for a designated panel of patients, emphasizing health promotion, chronic care management, patient self-management support, and overall wellness. Collaborate with the PACT team 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.
Educate patients and families and advocate for patients' needs to enhance patient outcomes and wellness. Champion a collaborative team approach for managing patient panels, ensuring continuity and quality of care tailored to individual patient goals and needs.
Provide primary care coordination for the PACT, oversee transitions of care, develop and implement Veteran-centered nursing care, deliver preventive and chronic disease management interventions, and provide care through multiple modalities, including face-to-face visits, virtual encounters, secure messaging, and telephone-based services. Utilize population health tools and evidence-based guidelines to identify and manage high-risk and chronically ill patients.
Collaborate with interdisciplinary team members, apply structured appointment grids, and engage in panel management to optimize health outcomes, support self-management, and reduce avoidable complications.
Provide 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 and improve outcomes for the immediate practice setting.
Coordinate same-day needs and post-discharge transitions by managing procedures, labs, follow-up, pre-visit preparation, clinical reminders, and referrals. Ensure Veterans receive appropriate services, specialty care, and interdisciplinary team resources.
Identify and manage patients requiring RN care through daily huddles and team collaboration; individualized care, health coaching and motivational interviewing, and deliver ongoing management for patients with chronic and ambulatory care sensitive conditions. Provide individualized care, health coaching and motivational interviewing, and deliver ongoing management for patients with chronic and ambulatory care sensitive conditions. Other duties as assigned.
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 to Friday, 7:30am to 4:00pm Telework: Not available Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not Authorized. Permanent Change of Station (PCS): Not Authorized.
V19USAJOBS@VA.GOV · 719-227-4600
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $80673 – $143666/yr.
Applications close on 2026-09-25.
This position is open under the 'Fed Internal Search' hiring path.
Source: USAJOBS.gov — U.S. Federal Government
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