PACT Registered Nurse Care Manager

U.S. Department of Veterans Affairs; Slidell (LA); On-site; USD 70,000 - 110,000; Full time

Job summary

The U.S. Department of Veterans Affairs seeks an Outpatient Primary Care RN Care Manager (PACT RNCM) to coordinate care for a patient panel, deliver fundamental knowledge-based nursing, and support transitions between care settings.

role emphasizes population health, self-management, and preventive care within a Veteran-centered team. Responsibilities include coordinating care across modalities—face-to-face visits, virtual encounters, secure messaging, and phone-based services—while applying

Qualifications

• English proficiency required for direct patient care.
• Graduate of an approved professional nursing program.
• Current RN licensure in at least one US state or territory.

Responsibilities

• Coordinate care for a designated patient panel within PACT.
• Provide knowledge-based primary nursing care and care coordination.
• Deliver care through multiple modalities including in-person, telehealth, and secure messaging.
• Participate in daily huddles and collaborate with interdisciplinary team.
• Utilize evidence-based guidelines and VA/DoD practices to improve outcomes.

Skills

English language proficiency

Education

Registered nursing degree

Job description

Summary

The Patient Aligned Care Team (PACT) Registered Nurse Care Manager (RNCM): Outpatient Primary Care (PC) delivers fundamental knowledge-based nursing care and care coordination within the Primary Care PACT. The PACT RNCM provides fundamental - knowledge-based - coordinated nursing care to panels of patients.

Qualifications

• English Language Proficiency
• In accordance with 38 U.S.C. 7403(f) - no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English
• Graduate of a school of professional nursing approved by the appropriate 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)
• OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program
• Upon achievement of a State license - the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program
• (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 to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program
• Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD)
• 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
• Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements - but do not possess the required licensure - may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.) NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification
• Grade Determinations: The following Scope - Education and Dimension criteria must be met in determining the grade assignment of candidates - and if appropriate - the level within a grade
• The Dimension requirements (Practice - Veteran/Patient Driven Care - Leadership - Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: https://apply.usastaffing.gov/ViewQuestionnaire/13070069
• Grade/Level Scope Education Nurse I - Level I Delivers fundamental - knowledge-based care to assigned clients while developing technical competencies
• An Associate Degree (ADN) or Diploma in Nursing - with no additional professional nursing required
• Nurse I - Level II Demonstrates integration of biopsychosocial concepts - cognitive skills and technically competent practice in providing care to clients with basic or complex
• An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I - Level 1 ;OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required
• Nurse I - Level III Demonstrates proficiency in practice based on conscious and deliberate planning
• Self-directed in goal setting for managing complex client situations
• An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I - Level 2
• OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I - Level 2
• OR a Master's degree in nursing (MSN) and no additional professional nursing experience
• OR a Master's degree in a *related field with a BSN and no additional professional nursing experience
• Nurse II Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others
• A BSN with 2 years of professional nursing equivalent to Nurse I - Level 3
• OR an MSN with one year of specialized nursing experience equivalent to Nurse I - Level 3
• OR a Master's degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse I - Level 3
• OR a Doctoral degree in Nursing with no professional nursing experience
• OR a Doctoral degree in a *related field with a BSN with no professional nursing experience
• Nurse III Executes position responsibilities that demonstrate leadership - experience and creative approaches to management of complex client care beyond the immediate practice setting
• MSN and 2 years of specialized nursing experience - one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Master's degree in *related field with BSN and two years of specialized nursing experience - one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Doctoral degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III
• *Note: Foreign education programs/degrees are not creditable as related degrees
• Preferred Experience: Outpatient Ambulatory Care PACT RN Care Manager - Strong ambulatory/primary care nursing experience - preferably within PACT or a similar patient-centered medical home model - Demonstrated care coordination and case management skills - including hypertension - diabetes - preventive care - and HEDIS/eQM quality measures - Strong clinical assessment - triage - and critical-thinking skills with appropriate escalation of changes in condition - Effective interdisciplinary collaboration with providers - LPNs - MSAs - pharmacy - social work - and specialty services - Demonstrated ability to prioritize workload and independently manage a patient panel - including secure messages - alerts - follow-up - and care coordination - Experience utilizing virtual care modalities such as VVC - telephone care - and remote patient monitoring - Proficient with electronic health records and clinical documentation - preferably VA systems - BSN preferred with applicable ambulatory care - case management - or nursing specialty certification desirable
• Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/.
  

Duties

• The PACT RNCM acts as the coordinator for a designated panel of patients - emphasizing health promotion - chronic care management - patient self-management support - and overall wellness
• This role focuses on proactive - patient-centered care by using nursing knowledge - evidence-based guidelines - and standardized nursing procedures/protocols
• Provides fundamental primary care coordination for the PACT - supporting transitions of care - collaborating in Veteran-centered nursing care - delivering preventive and chronic disease management interventions - and providing fundamental care through multiple modalities - including face-to-face visits - virtual encounters - secure messaging - and telephone-based services
• Awareness of population health tools and knowledge of evidence-based guidelines to identify and manage high-risk and chronically ill patients
• serves on the interdisciplinary team - applies structured appointment grids - and engages in proactive panel management to optimize health outcomes - support self-management - and reduce avoidable complications
• Knowledge of proactive - evidence-based care management using clinical reminders - policy orders/nurse protocols - and population health tools - and the ability to deliver fundamental chronic disease management - preventive health services - patient education - and health coaching to support Veteran-centered goals
• Collaborates in the coordination of same-day needs and post-discharge transitions by completing procedures - labs - follow-up - pre-visit preparation - clinical reminders - and referrals
• works to connect Veterans with appropriate services - specialty care - and interdisciplinary team resources
• Participates in daily huddles and collaborates with others to manage patients requiring RN care
• provides individualized care - health coaching and motivational interviewing - and ongoing management for patients with chronic and ambulatory care-sensitive conditions
• Knowledge of data-driven risk indicators to identify rising and high-risk patients and awareness of focused panel management prioritization and referral coordination for care management
• Connects patients with wraparound services
• participates in the coordination of care to provide smooth transitions between acute and ambulatory settings for patients with chronic disease - population health - post-discharge - or acute needs
• Delivers ongoing - fundamental RN-led chronic disease management using Veterans Affairs/Department of Defense (VA/DOD) clinical practice guidelines - evidence-based guidelines - health coaching - and collaboration with extended team members to support patient self-management - goal setting - and improved clinical outcomes
• 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 - preplanning - and daily communication to support access - continuity - quality - and patient experience while facilitating efficient - patient-ready visits
• Awareness of Whole Health principles and appropriate task delegation to strengthen team functioning - enhance care coordination - and meet PACT performance goals
• Knowledge of team metrics and VHA panel management tools to identify care gaps - prepare patient data - and support proactive - high-quality primary care delivery
• Demonstrates accountability - reliability - flexibility - teamwork - and adaptability in a fast-paced outpatient environment
• 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 07:30am - 04:00pm
• Subject to change based on the needs of the facility
• Telework: Not Available Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized