Registered Nurse - Patient Aligned Care Team Care Manager

U.S. Department of Veterans Affairs; Saint Cloud (MN); On-site; USD 75,000 - 95,000; Full time

Job summary

The U.S. Department of Veterans Affairs in Saint Cloud, MN seeks a Registered Nurse Care Manager within the Patient Aligned Care Team to coordinate outpatient primary care.

The RNCM delivers self-directed, comprehensive nursing care and supports transitions of care for a panel of Veterans. This role emphasizes health promotion, chronic disease management, and patient self-management using evidence-based guidelines and multi-modal delivery, including in-person visits, telehealth and secure

Qualifications

• Graduate of an approved nursing program and eligible for RN licensure in the US.
• Current, full, active RN license in a US state or territory.
• Proficiency in basic written and spoken English for direct patient care.
• Understanding of VA qualification standards and licensure requirements.
• Ability to pursue licensure beyond initial education per state rules.

Responsibilities

• Coordinate care for a designated PACT panel, emphasizing health promotion and chronic care management.
• Provide comprehensive, patient-centered nursing care with appropriate supervision as needed.
• Facilitate care transitions and ensure timely access to health care resources.
• Deliver care via multiple modalities: in-person visits, virtual encounters, secure messaging, and telephone-based services.

Skills

English proficiency

Education

RN license (US state)

Graduate nursing program (ACEN/CCNE)

Job description

Summary

The Patient Aligned Care Team (PACT) Registered Nurse Care Manager (RNCM): Outpatient Primary Care (PC) demonstrates proficiency in practice providing nursing care and care coordination based on conscious and deliberate planning within the Primary Care PACT. The PACT RNCM is self-directed in functioning as a team member providing comprehensive - coordinated nursing care to panels of patients with occasional supervision.

Summary

The Patient Aligned Care Team (PACT) Registered Nurse Care Manager (RNCM): Outpatient Primary Care (PC) demonstrates proficiency in practice providing nursing care and care coordination based on conscious and deliberate planning within the Primary Care PACT. The PACT RNCM is self-directed in functioning as a team member providing comprehensive - coordinated nursing care to panels of patients with occasional supervision.

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/13076193
• 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 and 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
• Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• Physical Requirements: You may be asked to participate in a pre-employment examination or evaluation as part of the pre-employment process for this position
• Questions about physical demands or environmental factors may be addressed at the time of examination/evaluation.

Duties

• The Patient Aligned Care Team (PACT) Registered Nurse Care Manager (RNCM): Outpatient Primary Care (PC) manages care coordination for a designated panel of patients - emphasizing health promotion - chronic care management - patient self-management support - and overall wellness
• They collaborate with the PACT members - extended care support team - and external services to develop and implement holistic - patient-driven care - facilitate care transitions - and provide timely - coordinated access to health care resources
• Major duties include but are not limited to: Self-directed in providing primary care coordination for the Patient Aligned Care Team (PACT) - overseeing transitions of care - developing and implementing Veteran-centered nursing care - delivering preventive and chronic disease management interventions - and providing care through multiple modalities - including face-to-face visits - virtual encounters - secure messaging - and telephone based services with occasional supervision
• Applies evidence-based care management using clinical reminders - policy orders/nurse protocols - and population-health tools - delivering chronic disease management - preventive health services - patient education - and health coaching to support Veteran-centered goals across all stages of care
• Identifies and manages assigned patients requiring RN care through daily huddles and team collaboration
• develops individualized care - provides health coaching and motivational interviewing - and delivers ongoing management for patients with chronic and ambulatory care-sensitive conditions
• Uses data-driven risk indicators to identify rising- and high-risk patients - prioritize focused panel management - and coordinate appropriate referrals for enhanced care management
• Delivers ongoing RN-led chronic disease management using Veterans Affairs/Department of Defense (VA/DOD) clinical guidelines - evidence-based guidelines - health coaching - and collaboration with extended team members to support patient self-management - goal setting - and improved clinical outcomes
• Monitors assigned PACT metrics and uses VHA panel-management tools to identify care gaps - prepare patient data - and support proactive - high-quality primary 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: Monday - Friday 8:00AM to 4:30PM Telework: Not Available Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized The VA Midwest Health Care Network advocates for a Whole Health System of care in each of the Medical Centers
• This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest
• As an employee operating in a Whole Health System of care - you will operate in a model with three core elements - seeking to create a personalized health plan for each Veteran
• This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community
• This aligns with the Veterans Health Administration (VHA) Mission Statement to Honor America's Veterans by providing exceptional health care that improves their health and well-being.