Registered Nurse - Patient Aligned Care Team Care Manager (IMC & GEM Clinic Float)

The Patient Aligned Care Team (PACT) Registered Nurse Care Manager (RNCM): Outpatient Primary Care (PC) 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 patients.

Major Duties:

• Serves as the primary care coordinator for a designated panel of patients within the Patient Aligned Care Team (PACT), providing comprehensive, patient-centered nursing care and care coordination.

• Accountable for all elements of the nursing process, emphasizing patient education, self-management, health promotion, chronic disease management, wellness, and customer satisfaction.

• Leads proactive, evidence-based nursing practice by applying clinical guidelines, nursing protocols, quality improvement principles, and population health strategies to improve patient outcomes.

• Coordinates and manages transitions of care across inpatient, outpatient, specialty, and community settings, ensuring timely access to appropriate healthcare resources and services.

• Provides care through multiple modalities, including face-to-face visits, virtual care, telephone encounters, and secure messaging.

• Uses population health tools, risk stratification, and panel management techniques to identify high-risk patients, close care gaps, prevent complications, and improve health outcomes.

• Delivers RN-led chronic disease management, preventive care, health coaching, motivational interviewing, and individualized care planning to support patient goals and self-management.

• Coordinates same-day care needs, post-discharge follow-up, referrals, laboratory and diagnostic testing, clinical reminders, procedures, and pre-visit planning.

• Collaborates with interdisciplinary team members, extended care support teams, patients, families, and community resources to develop and implement holistic, Veteran-centered care plans.

• Advocates for patients and families through education, support, and facilitation of services that promote continuity of care, wellness, and improved outcomes.

• Participates in daily huddles, pre-planning activities, and ongoing team communication to support access, continuity, quality, patient experience, and efficient clinic operations.

• Applies Whole Health principles and appropriate task delegation to strengthen team performance, care coordination, and achievement of PACT goals.

• Monitors performance metrics and utilizes VHA panel management tools to identify care gaps, support data-driven decision-making, and improve quality outcomes.

• Demonstrates leadership in professional nursing practice through evidence-based care, collaborative teamwork, resource management, and continuous quality improvement.

• Practices in accordance with applicable Nurse Practice Acts and licensure requirements governing professional nursing practice.

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, 7:30am-4:00pm
Telework: Ad-Hoc Only.
Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized

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/13089864. 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.

Preferred Experience:

• Three years Nurse Experience
• BSN
• Primary Care/PACT Experience
• Triage/Telephone Triage
• BLS certification required

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.

Physical Requirements: Pre-Employment/Post-Employment Physical Examination: May be required, depending on the needs of the organization.

The Associate Degree Nursing (ADN), Bachelor of Science degree in Nursing (BSN), or Master of Science degree in Nursing (MSN) must be fully accredited by the Accreditation Commission for Education in Nursing (ACEN) or the Commission On Collegiate Nursing Education (CCNE). Verification of accreditation may be obtained from http://www.acenursing.us/accreditedprograms/programsearch.htm or https://directory.ccnecommunity.org/reports/accprog.asp

• If your school has changed names, or is no longer in existence, you must provide this information in your application.
• If your school was accredited by ACEN or CCNE at the time of graduation, but is no longer listed on the websites, you must provide documentation of accreditation with your application packet.

If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.