The Patient Aligned Care Team (PACT) Registered Nurse Care Manager (RNCM): 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. The PACT RNCM assumes responsibility for the coordination of care focused on patient education, self-management, and customer satisfaction.
Assigned Duties: 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.
- Utilizes population health tools and evidence-based guidelines to identify and manage high-risk and chronically ill patients to improve quality of care and resource utilization at the expert level with improved outcomes beyond the immediate practice setting; collaborates with interdisciplinary team members, at the expert level, to apply structured appointment grids, and engage in proactive panel management to optimize health outcomes, support self-management, and reduce avoidable complications.
Patient Care/Customer Service: - Provides 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. Leads initiatives to improve Veteran/patient experience.
- 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.
- Demonstrates expertise in identifying and managing patients requiring RN care through daily huddles and team collaboration; develops individualized care, provides health coaching and motivational interviewing, and delivers ongoing management for patients with chronic and ambulatory care-sensitive conditions resulting in improved evidence-based and/or data-driven outcomes beyond the immediate practice setting.
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. - Delivers ongoing RN-led chronic disease management using Veterans Affairs/Department of Defense (VA/DOD) clinical guidelines, evidence-based guidelines, health coaching, and collaboration with extended team members to support patient self-management, goal setting, and optimized clinical outcomes.
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.
- Applies Whole Health principles and appropriate task delegation to strengthen team functioning, enhance care coordination, and meet PACT performance goals. - Monitors team metrics and uses VHA panel-management tools to identify care gaps, improve patient data, and lead proactive, high-quality primary care delivery with positive impact beyond the immediate practice setting.
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 8:00am-4:30pm Telework: Not Available Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized
jessica.williamson@va.gov · 315-751-8436
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $70887 – $118557/yr.
This position requires a Other security clearance.
Applications close on 2026-10-06.
This position is open under the 'Public' hiring path.
Source: USAJOBS.gov — U.S. Federal Government
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