Registered Nurse- Primary Care- Care Manager

U.S. Department of Veterans Affairs; Manchester (NH); On-site; USD 90,000 - 120,000; Full time

Benefits offered by this job

Education Debt Reduction Program (EDRP

Job summary

The U.S. Department of Veterans Affairs, Manchester VA, seeks a Registered Nurse for Primary Care Care Management in the outpatient setting.

This role emphasizes care coordination within the PACT, implementing preventive and chronic disease management, and collaborating with an interdisciplinary team to optimize veteran health outcomes. Candidates must hold a valid state nursing license, have an accredited nursing degree, and be proficient in English.

Qualifications

• English proficiency required for direct patient care
• Nursing degree from ACEN/CCNE-accredited program or equivalent
• Current, full, active nursing license in the United States
• Option to start via bridge program leading to licensure; temporary appointment then permanent
• Graduate Nurse Technician exception for licensure pursuit
• Two to three years of professional nursing experience in Primary Care/Ambulatory Care preferred

Responsibilities

• Provide fundamental primary care coordination for the Patient Aligned Care Team (PACT)
• Support transitions of care and collaborate in Veteran-centered nursing care
• Deliver preventive and chronic disease management interventions through multiple modalities
• Engage in team huddles and proactive panel management to improve health outcomes
• Utilize evidence-based guidelines and clinical reminders for care management
• Coordinate same-day needs, post-discharge transitions, labs, referrals, and follow-ups

Skills

English proficiency

Nursing care

Team collaboration

Patient education

Education

Nursing degree with licensure

State nursing license

Job description

Summary

This position is eligible for the Education Debt Reduction Program (EDRP) - a student loan payment reimbursement program. You must meet specific eligibility requirements per VHA policy and submit your EDRP application within four months of appointment. Program Approval - award amount (up to $200 -000) & eligibility period (one to five years) are determined by the VHA Education Loan Repayment Services program office after review of the EDRP application. Former EDRP participants ineligible to apply.

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
• Preferred Experience: At least 2-3 years professional experience working in Primary Care or Ambulatory Care setting
• 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/13073214
• 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: All applicants must be physically able to satisfactorily perform the duties of the position
• A pre placement examination shall be completed prior to appointment.

Duties

• This Registered Nurse- Primary Care- Care Manager is located in the Nursing - Outpatient Primary Service at the Manchester VA location
• This position is full-time at 40 hours per week
• Duties are Included but are not limited to: 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
• Work Schedule: Full-Time - Monday-Friday 7:30 A.M- 4:00 P.M or 8:00 A.M to 4:30 P.M
• Telework: Not Available
• Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not Authorized
• EDRP Authorized: Former EDRP participants ineligible to apply for incentive
• Contact [e-mail] - the EDRP Coordinator for questions/assistance
• Learn more
• Permanent Change of Station (PCS): Not Authorized
• Notifications: This is not a Bargaining Unit Position This position is in the Excepted Service This position is covered by a special rate
• Current and former Federal employees must submit copies of their most recent SF-50 - (Notice of Personnel Action)
• The SF-50 must identify the position title - series - grade - step - tenure and type of service (Competitive or Excepted)
• In some cases - more than one SF-50 may be required to show a higher grade previously held
• 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
• VA offers a comprehensive total rewards package: VA Nurse Total Rewards