Registered Nurse - Patient Aligned Care Team (PACT) Care Manager

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

Job summary

U.S. Department of Veterans Affairs in Fargo, ND seeks a Patient Aligned Care Team (PACT) Registered Nurse (RN) Care Manager to coordinate care for an assigned panel of patients in a clinic setting, focusing on high-risk patients, care transitions, and population health strategies with the PACT and multidisciplinary teams.

The RN will develop, implement, and update patient-driven care plans using nursing best practices, provide health education and coaching, and collaborate with VA services and

Qualifications

• English language proficiency as per VA requirements.
• Graduate of a nursing program accredited by ACEN or CCNE or equivalent.
• State license in nursing upon appointment and ability to obtain licensure.
• Foreign education must be evaluated for equivalence where applicable.

Responsibilities

• Serve as primary point of contact for care management for an assigned patient panel.
• Develop and implement individualized, patient-driven care plans with interdisciplinary teams.
• Provide health education, coaching, and counseling to patients and families.
• Coordinate with VA and community resources for transitions and population health strategies.
• Participate in performance improvement activities and use data to close care gaps.

Skills

English language proficiency

Education

Associate Degree in Nursing

Bachelor of Science in Nursing

Master's degree in Nursing

State nursing license

Job description

Summary
The Patient Aligned Care Team (PACT) Registered Nurse (RN) Care Manager will utilize the nursing process and evidence based practice to deliver and manage comprehensive care to an assigned panel of patients in a clinic setting. The RN is a key member of the PACT and multidisciplinary team and is responsible for collaboration with other team members - promoting effective communication and ethical practice.

Summary
The Patient Aligned Care Team (PACT) Registered Nurse (RN) Care Manager will utilize the nursing process and evidence based practice to deliver and manage comprehensive care to an assigned panel of patients in a clinic setting. The RN is a key member of the PACT and multidisciplinary team and is responsible for collaboration with other team members - promoting effective communication and ethical practice.
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: Experience in Primary Care or outpatient clinical area 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/13067962
• 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 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 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 will 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 evaluation or examination.
  

Duties

• 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
• 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 The primary duties for the PACT RN Care Manager include - but are not limited to: Serve as the primary point of contact for care management and coordination for an assigned patient panel - focusing on high-risk patients - care transitions - and population health strategies utilizing data resources
• Use nursing expertise - evidence-based guidelines - and standardized protocols to develop - implement - and update individualized - patient-driven care plans in collaboration with interdisciplinary teams and patients/families
• Provide health education - coaching - and counseling to patients and families - emphasizing self-management - prevention - wellness - and shared decision-making
• Work actively with the PACT Team - internal and external VA services - and community-based resources to assess patient needs - support care transitions - and ensure comprehensive patient care
• Participate in performance improvement activities - utilize patient registries and data resources for population health management - and monitor outcomes to identify care gaps and enhance patient wellness
• Maintain current knowledge of multidisciplinary resources and programs - refer patients as appropriate - and serve as a resource for navigating the healthcare system and processes
• Assess patients for telehealth and home monitoring devices - utilize VA Video Connect - Document all patient interactions and interventions in the patient record - complete encounters for workload credit - and support compliance with standards and nursing practice aligned with Primary Care ICC and CAN Score management
• Work Schedule: Monday through Friday
• 8:00 am to 4:30 pm Telework: Not Available Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized