The Patient Aligned Care Team (PACT) Care Manager RN uses the nursing process and evidence-based practice to collaborate with the Core Team (Patient, Primary Care Provider, RN Care Manager, Clinical Associate, Clerical Associate, PACT neighbors) and Expanded Team (family/caregiver, internal and community-based services involved in providing care to the patient) in developing the patient-driven holistic care plan for life. He or she utilizes the PACT Almanac, Compass, Quality Metric Report, other data sources, and Population Health Management principles to drive panel management. Triages and applies a collaborative team approach in identifying, analyzing, and resolving patient care problems.
Monitors patients at high risk for hospitalization and keeps Primary Care Provider apprized of clinical issues needing provider interventions. Monitors high risk, high volume and problem prone patients throughout their lifespan.
Provides post discharge and emergency room telephone calls to teamlet panel to ensure transition, assesses current needs, and appoints as needed for follow up care. The RN Care Manager is responsible for collaborating with services internal and external to the VA to facilitate care transition in order to effectively meet the patients' needs.
The RN Care Manager provides patient and family health education with a focus on self-management, prevention, and wellness based on the patient's goals. Supports implementation of group and shared medical appointments to meet the needs of the patient panel. Applies skills, such as motivational interviewing to promote patient self-management toward patient-driven holistic care plan for life.
The RN Care Manager demonstrates leadership by serving as an advocate for patients and team player to colleagues. He or she continues to enhance his or her own, as well as the team's, professional growth, development, and practice. The RN Care Manager will consistently demonstrate technical skills as well as comprehensive knowledge of the program which he or she coordinates without the need for direct supervision.
Work Schedule: Monday through Friday, 8:00 am to 4:30 pm.
Financial Disclosure Report: Not Required.
- 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.
Grade Determinations: The following criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade:
- 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.
Other Factors: The incumbent must be a mature, flexible, sensible individual, able to shift priorities based on patient needs. The incumbent must be poised and articulate in communicating with people of varied educational levels and ethnic backgrounds; willing to work cooperatively as a member of a team in all assignments; self-motivated in the pursuit of meeting professional work standards; able to demonstrate customer service principles in all aspects of work, making the care of the veteran his or her priority while in the work setting.
Selected applicants will be required to complete an online on-boarding process.
To apply for this position, you must provide a complete Application Package which includes:
- Cover Letter
- Other Veterans Document