PACT RN Care Manager - Primary Care & Care Coordination

Veterans Health Administration; Slidell (LA); On-site; USD 74,000 - 140,000; Full time

Job summary

The Veterans Health Administration in Slidell, LA seeks a PACT Registered Nurse Care Manager (RNCM) to deliver fundamental knowledge-based nursing care and care coordination within the Primary Care PACT.

The role emphasizes proactive, patient-centered care, health promotion, and chronic disease management, using various modalities including face-to-face visits, virtual encounters, secure messaging, and telephone-based services.

Qualifications

Responsibilities

• 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.
• 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.

Job description

The Veterans Health Administration in Slidell, LA seeks a PACT Registered Nurse Care Manager (RNCM) to deliver fundamental knowledge-based nursing care and care coordination within the Primary Care PACT.

The role emphasizes proactive, patient-centered care, health promotion, and chronic disease management, using various modalities including face-to-face visits, virtual encounters, secure messaging, and telephone-based services.