PACT RN Care Manager: Primary Care & Care Coordination

Diversity Group; Altoona (PA); On-site; USD 70,000 - 110,000; Full time

Job summary

Diversity Group is seeking an experienced Patient Aligned Care Team (PACT) Registered Nurse Care Manager (RNCM) for outpatient primary care. The RNCM delivers comprehensive, coordinated nursing care to panels of veterans, often with supervision, focusing on transitions of care and chronic disease management.

Responsibilities include care coordination across modalities, engagement with an interdisciplinary team, and use of population health tools to identify high-risk patients, aiming to improve

Qualifications

• English language proficiency required by VA standards.
• Graduate of a nursing program approved by accrediting bodies (ACEN/CCNE).
• May include bridge program pathway to RN licensure.
• Foreign nursing grads require degree equivalency validation.

Responsibilities

• Provides primary care coordination for the PACT, overseeing transitions of care and chronic disease management.
• Collaborates with interdisciplinary team using population health tools to identify high-risk patients.
• Delivers care via multiple modalities: in-person, virtual, secure messaging, and phone.
• Utilizes clinical reminders and nurse protocols to support patient self-management.
• Monitors care gaps and uses panel management tools to improve outcomes.
• Provides health coaching and Motivational Interviewing for veterans under care.

Skills

English Language Proficiency

Nursing Knowledge

Care Coordination

Team Collaboration

Education

RN licensure (State)

Nursing degree (RN)

Bridge program eligibility (MSN bridge)

Foreign nursing education recognition

Job description

Diversity Group is seeking an experienced Patient Aligned Care Team (PACT) Registered Nurse Care Manager (RNCM) for outpatient primary care. The RNCM delivers comprehensive, coordinated nursing care to panels of veterans, often with supervision, focusing on transitions of care and chronic disease management.

Responsibilities include care coordination across modalities, engagement with an interdisciplinary team, and use of population health tools to identify high-risk patients, aiming to improve