RN - Care Manager Patient Aligned Care Team (PACT)
The Patient Aligned Care Team (PACT) RN Care Manager (RNCM) is a licensed professional RN who is assigned to a designated panel of patients within Primary Care. The PACT RNCM works in partnership with other team members, which includes the patient, to effectively and efficiently deliver and manage preventative, proactive, patient-driven care and chronic disease management and care needs. The RNCM demonstrates leadership in delivering efficient, comprehensive, and continuous patient-driven holistic care through active patient care, collaboration, communication, and coordination of resources.
The RNCM actively collaborates with the PACT team members (patient, provider, Medical Support Assistant (MSA), and LPN) and larger Team (family/caregiver, internal and community-based services) in supporting the patient centered, patient-driven holistic plan of care. The RN Care Manager uses the nursing process and evidence-based practice to provide proactive, preventative and patient-driven care. As a member of the patient-aligned care team (PACT), the RN Care Manager is responsible for collaborating with services internal and external to the VA to facilitate and coordinate care transition in order to effectively and safely meet the patients' needs. The RNCM provides patient and family health education with a focus on self-management, prevention, and wellness, based on the patient's goals. The RNCM serves as an advocate for patients and actively engages with his/her team and colleagues as she/he continues to enhance his/her own and the team's professional growth, development and practice. Duties include but not limited to:
- Demonstrates advanced clinical knowledge in assessing, planning, implementing, documenting, and evaluating care for a panel of patients across the continuum of care, recognizing the age related cognitive, physical, emotional, and chronological maturation needs of the adult and geriatric patient.
- Participates in chronic disease management for panel in collaboration with provider. Engages in Shared Medical Appointments (SMA), and/or RNCM visits.
- Utilizes the Primary Care Almanac and PACT Metrics to address population health management issues and improve Team processes.
- Triages and applies a collaborative team approach in identifying, analyzing, and resolving patient care problems.
- Assists in determining appropriate scheduling based on patient's clinical need. Right person, right place, right time
- Collaborates with ancillary team members and resources within the clinic to manage clinic access issues. This may include assisting other nursing staff with maintaining clinic flow.
- Promotes patient, family and team interactions, and problem solving by actively participating in interdisciplinary meetings to facilitate coordination and the achievement of identified goals.
- Retains current knowledge of multidisciplinary resources, programs, and services, referring patients for community resources as appropriate. Demonstrates ability to collaborate and coordinate with all levels of services and disciplines.
- Collaborate with patients to assess and identify needs, issues, care goals, and resources for achieving desired outcomes post hospital recovery and health maintenance/wellness by effectively using Motivational Interviewing and TEACH techniques.
- Supports patient self-management by providing an ongoing relationship with the PACT with current information regarding all options, choices, and resources. Provides patient centered care while respecting patient's personal values, cultural, and belief system.
- Utilizes approved Protocols and Guidelines to facilitate autonomy in providing care. Works at the top of scope of practice.
- Accurately documents coordination and care provided in CPRS.
- Manages patient care alerts in CPRS in a timely, safe and effective manner.
- Serves as a resource for patient and family rights, responsibilities, and decision-making information and processes.
- Actively participates in reviewing and updating policies, procedures, and standards to promote evidence-based, patient-driven care.
- Maintains professional knowledge and skills based on current evidence-based practice. Maintains expertise in chronic care/disease management and Health Promotion/Disease Prevention.
- Maintains effective working relationships with professionals and support personnel within the medical center and the community.
- Applies critical thinking and analytical skills to identify barriers for optimal patient care delivery and utilizes processes improvement strategies to correct or improve current state.
- Utilizes creativity and innovation. Recommends and participates in interdisciplinary opportunities to improve patient care or clinical efficiency.
- As needed, provides back-up coverage for other team members and other PACT RNCM within the clinic.
Financial Disclosure Report: Not RequiredTo qualify for this position, applicants must meet all requirements within 30 days of the closing date of this announcement.
- United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
- Graduate of a school of professional nursing approved by the appropriate State-accrediting agency and accredited by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE). In cases of graduates of foreign schools of professional nursing, possession of current, full, active and unrestricted registration will meet the requirement of graduation from an approved school of professional nursing. OR The completion of coursework equivalent to a nursing degree in a MSN Bridge Program that qualifies for professional nursing registration constitutes the completion of an approved course of study of professional nursing. Students should submit the certificate of professional nursing to sit for the NCLEX to the VA along with a copy of the MSN transcript. (Reference VA Handbook 5005, Appendix G6) OR In cases of graduates of foreign schools of professional nursing, possession of a current, full, active and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing.
- Current, full, active, and unrestricted registration as a graduate professional nurse in a State, Territory or Commonwealth (i.e., Puerto Rico) of the United States, or the District of Columbia.
- Bachelor's Degree in Nursing (BSN) AND one (1) year RN nursing experience OR;
- Associate's Degree in Nursing (ADN) AND two (2) years RN nursing experience at Veterans Affairs Salt Lake City Healthcare System OR;
- Associate's Degree in Nursing (ADN) AND three (3) years RN nursing experience
- Nurse I Level I - An Associate Degree (ADN) or Diploma in Nursing, with no additional nursing practice/experience required.
- Nurse I Level II - An ADN or Diploma in Nursing and approximately 1 year of nursing practice/experience; OR an ADN or Diploma in Nursing and a bachelor's degree in a related field with no additional nursing practice/experience; OR a Bachelor's of Science in Nursing (BSN) with no additional nursing practice/experience.
- Nurse I Level III - An ADN or Diploma in Nursing and approximately 2-3 years of nursing practice/experience; OR an ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 1-2 years of nursing practice/experience; OR a BSN with approximately 1-2 years of nursing practice/experience; OR a Master's degree in nursing (MSN) or related field with a BSN and no additional nursing practice/experience.
- Nurse II - A BSN with approximately 2-3 years of nursing practice/experience; OR ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 2-3 year's of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 year's of nursing practice/experience; OR a Doctoral degree in nursing or meets basic requirements for appointment and has doctoral degree in a related field with no additional nursing practice/experience required.
- Nurse III - Master's degree in nursing or related field with BSN and approximately 2-3 year's of nursing practice/experience; OR a Doctoral degree.
Selected applicants will be required to complete an online onboarding process.
To apply for this position, you must provide a complete Application Package which includes:
The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist to ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's, etc.
- Cover Letter
- Other Veterans Document