PACT RN Care Manager: Lead Chronic Care & Wellness

Veterans Health Administration, Department of Veterans Affairs; Montevideo (MN); On-site; USD 75,000 - 105,000; Full time

Job summary

Veterans Health Administration in Montevideo is seeking a Patient Aligned Care Team (PACT) Registered Nurse Care Manager for outpatient Primary Care. The RNCM provides self-directed nursing care and care coordination for panels of patients in a collaborative team setting.

Responsibilities include health promotion, chronic disease management, and coordinating transitions of care across modalities, including in-person visits, telehealth, and secure messaging.

Qualifications

• English language proficiency required.
• Graduate of a nursing program approved by accrediting bodies (ACEN or CCNE).
• State license to practice as a registered nurse in the US.
• Advanced education options include master's level bridge programs in nursing or MSN with related qualifications.
• Foreign graduates must have current full, active, unrestricted registration in any US state or territory.

Responsibilities

• Manages care coordination for a designated patient panel emphasizing health promotion and chronic care management.
• Collaborates with PACT members and external services to provide holistic, patient-driven care and ensure timely access to care resources.
• Educates patients and families, advocating for patient needs to improve outcomes and wellness.
• Leads a team-based approach to manage patient panels, ensuring continuity and quality of care.Oversees transitions of care and implements veteran-centered nursing care using VA/DoD guidelines.
• Delivers RN-led chronic disease management and supports patient self-management and goal setting.
• Utilizes data-driven risk indicators to identify high-risk patients and coordinate referrals for enhanced care management.

Skills

English proficiency

Education

Graduate of professional nursing program

ACEN/CCNE accreditation

Master's bridge program in nursing

Current RN license in US

Job description

Veterans Health Administration in Montevideo is seeking a Patient Aligned Care Team (PACT) Registered Nurse Care Manager for outpatient Primary Care. The RNCM provides self-directed nursing care and care coordination for panels of patients in a collaborative team setting.

Responsibilities include health promotion, chronic disease management, and coordinating transitions of care across modalities, including in-person visits, telehealth, and secure messaging.