Registered Nurse (RN) Care Manager - Patient Aligned Care Team (PACT)

Quick Facts

• Role: Patient Aligned Care Team (PACT) Registered Nurse (RN) Care Manager

• Setting: Clinic-based primary care team

• Schedule: Monday–Friday, 8:00 am–4:30 pm

• Telework/virtual: Not available / not a virtual position

Description

The PACT RN Care Manager delivers and manages comprehensive care for an assigned patient panel using the nursing process and evidence-based practice. The RN partners with the multidisciplinary PACT team to coordinate care, support high-risk patients and transitions, and implement population health strategies. The role includes developing and updating patient-driven care plans, providing education and coaching, and documenting all interactions in the patient record.

Responsibilities

• Serve as the primary point of contact for care management and coordination for assigned patients

• Focus on high-risk patients, care transitions, and population health using data resources

• Develop, implement, and update individualized patient-driven care plans using evidence-based guidelines and standardized protocols

• Provide health education, coaching, and counseling to patients and families

• Coordinate with the PACT team, internal/external VA services, and community resources to support transitions and comprehensive care

• Participate in performance improvement activities; use patient registries and data resources to identify care gaps and enhance outcomes

• Maintain current knowledge of multidisciplinary resources and programs; refer patients and support navigation of the healthcare system

• Assess patients for telehealth and home monitoring devices; use VA Video Connect

• Document patient interactions and interventions in the patient record and complete encounters for workload credit

• Support compliance with standards and nursing practice aligned with Primary Care ICC and CAN Score management

Requirements

• U.S. citizenship (non-citizens only if allowed by VA policy)

• English language proficiency for direct patient care

• Graduate of an approved professional nursing program (ACEN/CCNE) or eligible bridge pathway

• Current, full, active, unrestricted RN licensure in a U.S. state/territory/commonwealth or the District of Columbia

• Pass pre-employment physical evaluation

• Subject to background/security investigation

• Selected applicants may be subject to urinalysis drug screening prior to appointment

• Complete required onboarding and application documentation

• Participation in seasonal influenza vaccination program is required

• Selective Service registration requirement for eligible males

Benefits

• Competitive salary, regular salary increases, and potential performance awards

• Paid Time Off: 50 days per year (annual leave, sick leave, and paid federal holidays)

• Retirement: traditional federal pension with vesting and federal 401K with up to 5% VA contributions

• Insurance: federal health/vision/dental/term life/long-term care options

• Licensure coverage: 1 full and unrestricted RN license from any U.S. state or territory