Registered Nurse - PACT Care Manager

U.S. Department of Veterans Affairs; Alamosa (CO); On-site; USD 80,000 - 110,000; Full time

Benefits offered by this job

Federal employee benefits

Paid time off

Job summary

U.S. Department of Veterans Affairs is seeking a Registered Nurse Care Manager to provide coordinated nursing care for panels of Veterans in primary care settings.

The role emphasizes evidence-based practice, transitions of care, and collaboration with interdisciplinary teams to improve health outcomes. Candidates should have an active RN license and be proficient in English, with readiness to support chronic disease management and preventive care across multiple modalities as part of the VA

Qualifications

• Graduate of an approved nursing program with active RN license.
• Current, full, active, and unrestricted RN license in the United States.
• English language proficiency per VA standards.
• Completion of ACEN/CCNE-accredited nursing program.
• Bridge program options for RN licensure eligibility.
• Licensure verification and/or bridge program progression as applicable.

Responsibilities

• Provide fundamental primary care coordination for Veterans in PACT teams.
• Support transitions of care and follow-up with patients.
• Deliver care across modalities: in-person, virtual, secure messaging, and telephone.
• Collaborate with interdisciplinary teams to improve patient outcomes.
• Utilize population health tools and guidelines to manage high-risk patients.
• Assist with care coordination for chronic conditions and preventive services.

Skills

English proficiency

Care coordination

Interdisciplinary teamwork

Patient education

Health coaching

Evidence-based practice

Education

Nursing degree (ADN/BSN)

Diploma/ADN in Nursing

Tools

EHR systems

Job description

Summary

The Registered Nurse Care Manager will provide fundamental - knowledge based - coordinated nursing care to panels of patients.

Qualifications

Basic Requirements:

• 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
• Preferred Experience: 2 years of RN experience with 1 year of Primary Care/Outpatient/Ambulatory Care experience preferred
• 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/13072901
• 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 additional 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
• Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• Physical Requirements: The position involves considerable standing - walking - stooping - bending - reaching - lifting - and turning
• It requires restraining confused patients - repositioning patients - assisting with transferring patients to Wheelchairs/stretchers/cars - and transporting them to other departments or facilities
• Mechanical devices available and are required to be used for heavy or difficult to lift patients
• The work may involve pushing or lifting weight in excess of 50 pounds and going up and down flights of stairs
• The RN may be exposed to infected patients and contaminated materials and may be required to don protective clothing in isolation situations or operative/invasive procedures
• This position requires visual acuity - good hearing - distinctive speech and manual dexterity
• The position requires the nurse to work for periods of time with arms above shoulder level with neck in a fully flexed or extended position and the ability to physically control or protect his/herself from physically abusive patients.

Duties

• https://youtu.be/EGW4PMZvJto?si=_f7pNchVqoK1KZal Duties and responsibilities include - but are not limited to - the following: Provide fundamental primary care coordination for the PACT - supporting transitions of care - collaborating in Veteran-centered nursing care - deliver preventive and chronic disease management interventions - and provide fundamental care through multiple modalities - including face to face visits - virtual encounters - secure messaging - and telephone-based services
• Aware of population health tools and knowledge of evidence-based guidelines to identify and manage high risk and chronically ill patients
• serve on the interdisciplinary team - apply structure appointment grids - and engage 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
• Collaborate in the coordination of same day needs and post-discharge transitions by completing procedures - labs - follow-up - pre-visit - preparation - clinical reminders - and referrals
• work to connect Veterans with appropriate services - specialty care - and interdisciplinary team resources
• Participate in daily huddles and collaborate with others to manage patients requiring RN care
• provide 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
• Connect patients with wraparound services
• participate in coordination of care to provide smooth transitions between acute and ambulatory settings for patients with chronic disease - population health - post-discharge - or acute needs
• Deliver 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
• Collaborate 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
• Aware 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 care delivery
• 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: Full-Time - 8:00am-4:30pm - M-F Telework: This position is authorized for telework - situational (ad hoc) and has NOT been authorized as virtual or remote
• Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized