Registered Nurse - Patient Aligned Team Care Manger

LeadingAge Virginia; West Virginia; On-site; USD 70,000 - 100,000; Full time

Job summary

LeadingAge Virginia is seeking a Patient Aligned Care Team (PACT) Registered Nurse Care Manager (RNCM) to oversee nursing care and care coordination for a patient panel in a primary care setting.

The RNCM will educate patients on self-management, coordinate transitions of care, and collaborate with interdisciplinary teams to improve access and outcomes. A valid nursing license and English proficiency are required.

Qualifications

• Graduate of an approved nursing program with current US licensure.
• Ability to obtain State license and practice in nursing within VA systems.
• Understanding of patient education, self-management, and care coordination.

Responsibilities

• Coordinate and manage care for an assigned patient panel.
• Lead chronic disease management, preventive care, and health promotion.
• Identify high-risk patients using population health tools and plan interventions.
• Coordinate transitions of care and ensure timely access to services.
• Educate patients and families and support self-management.

Skills

English proficiency

Nursing license

Leadership

Education

Nursing degree (ADN/ Diploma or BSN)

State licensure

Bridge program opportunity (MSN/BSN pathway)

Job description

Summary

The Patient Aligned Care Team (PACT) Registered Nurse Care Manager (RNCM) is responsible and accountable for all elements of the nursing process when providing nursing care and care coordination within the Primary Care PACT. The PACT RNCM assumes responsibility for the coordination of care focused on patient education - self-management - and customer satisfaction while functioning as a key team member providing comprehensive - 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
• 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/13097552
• 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: See VA Directive and Handbook 5019 - Employee Occupational Health Service for requirements.

Duties

• The PACT RNCM serves as the primary coordinator of care for an assigned patient panel - providing comprehensive - patient-centered nursing care focused on health promotion - chronic disease management - patient education - self-management - care coordination - and customer satisfaction
• Using evidence-based practice - clinical guidelines - nursing knowledge - and standardized protocols - the RNCM leads proactive care delivery to improve patient outcomes and wellness
• The RNCM collaborates with PACT team members - interdisciplinary partners - extended care support teams - and community resources to develop and implement Veteran-driven care plans - coordinate transitions of care - and ensure timely access to appropriate healthcare services
• Care is delivered through multiple modalities - including face-to-face visits - virtual care - secure messaging - and telephone encounters
• Key responsibilities include identifying and managing high-risk and chronically ill patients through population health tools - panel management - daily huddles - health coaching - motivational interviewing - chronic disease management - preventive care - and patient/family education
• The RNCM coordinates same-day care needs - post-discharge follow-up - referrals - laboratory and diagnostic services - and specialty care to ensure continuity and quality of care
• The RNCM monitors care gaps - utilizes data-driven risk stratification to prioritize interventions - coordinates wraparound services - and supports smooth transitions across care settings
• Additionally - the RNCM promotes collaborative team-based care - applies Whole Health principles - monitors panel and performance metrics - supports quality improvement initiatives - and facilitates efficient - patient-ready visits
• The RNCM demonstrates leadership in professional nursing practice through the integration of evidence-based care - quality improvement - resource stewardship - and advocacy for patient needs while adhering to all applicable nursing licensure and Nurse Practice Act requirements
• Key Functions Coordinate and manage care for an assigned patient panel
• Lead chronic disease management - preventive care - and health promotion efforts
• Identify and manage high-risk patients using population health and panel management tools
• Coordinate care transitions - post-discharge follow-up - referrals - and specialty care services
• Provide patient and family education - health coaching - and self-management support
• Collaborate with interdisciplinary teams to improve access - continuity - quality - and patient experience
• Monitor performance metrics - address care gaps - and support quality improvement initiatives
• Promote Veteran-centered - Whole Health care and optimize clinical outcomes through evidence-based practice
• 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: 8am to 430pm
• Telework: Not available
• Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not authorized
• Permanent Change of Station (PCS): Not authorized.