The Patient Aligned Care Team (PACT) RN Care Manager (RNCM) is a licensed professional RN who is assigned to a designated panel of patients within Primary Care. The PACT RNCM works in partnership with other team members, which includes the patient, to effectively and efficiently deliver and manage preventative, proactive, patient-driven care and chronic disease management and care needs.
Demonstrates advanced clinical knowledge in assessing, planning, implementing, documenting, and evaluating care for a panel of patients across the continuum of care, recognizing the age related cognitive, physical, emotional, and chronological maturation needs of the adult and geriatric patient.
Participates in chronic disease management for panel in collaboration with provider. Engages in Shared Medical Appointments (SMA), and/or RNCM visits.
Utilizes the Primary Care Almanac and PACT Metrics to address population health management issues and improve Team processes.
Triages and applies a collaborative team approach in identifying, analyzing, and resolving patient care problems.
Assists in determining appropriate scheduling based on patient's clinical need. Right person, right place, right time
Collaborates with ancillary team members and resources within the clinic to manage clinic access issues. This may include assisting other nursing staff with maintaining clinic flow.
Promotes patient, family and team interactions, and problem solving by actively participating in interdisciplinary meetings to facilitate coordination and the achievement of identified goals.
Retains current knowledge of multidisciplinary resources, programs, and services, referring patients for community resources as appropriate. Demonstrates ability to collaborate and coordinate with all levels of services and disciplines.
Collaborate with patients to assess and identify needs, issues, care goals, and resources for achieving desired outcomes post hospital recovery and health maintenance/wellness by effectively using Motivational Interviewing and TEACH techniques.
Accurately documents coordination and care provided in CPRS.
Serves as a resource for patient and family rights, responsibilities, and decision-making information and processes.
Actively participates in reviewing and updating policies, procedures, and standards to promote evidence-based, patient-driven care.
Maintains professional knowledge and skills based on current evidence-based practice. Maintains expertise in chronic care/disease management and Health Promotion/Disease Prevention.
As needed, provides back-up coverage for other team members and other PACT RNCM within the clinic.
Work Schedule: Monday through Friday 8:00 AM to 4:30 PM, Clinic has extended hours with requirement for late/early shift midweek.
Financial Disclosure Report: Not required
Job family (Series)
Conditions of Employment
You must be a U.S. Citizen to apply for this job
Designated and/or random drug testing required
Selective Service Registration is required for males born after 12/31/1959
You may be required to serve a probationary period
Subject to a background/security investigation
Must be proficient in written and spoken English
Selected applicants will be required to complete an online onboarding process
Must pass pre-employment physical examination
Grade Determinations: The following criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade:
Nurse I Level I - An Associate Degree (ADN) or Diploma in Nursing, with no additional nursing practice/experience required.
Nurse I Level II - An ADN or Diploma in Nursing and approximately 1 year of nursing practice/experience; OR an ADN or Diploma in Nursing and a bachelor's degree in a related field with no additional nursing practice/experience; OR a Bachelor's of Science in Nursing (BSN) with no additional nursing practice/experience.
Nurse I Level III - An ADN or Diploma in Nursing and approximately 2-3 years of nursing practice/experience; OR an ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 1-2 years of nursing practice/experience; OR a BSN with approximately 1-2 years of nursing practice/experience; OR a Master's degree in nursing (MSN) or related field with a BSN and no additional nursing practice/experience.
Nurse II - A BSN with approximately 2-3 years of nursing practice/experience; OR ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 2-3 year's of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 year's of nursing practice/experience; OR a Doctoral degree in nursing or meets basic requirements for appointment and has doctoral degree in a related field with no additional nursing practice/experience required.
Nurse III - Master's degree in nursing or related field with BSN and approximately 2-3 year's of nursing practice/experience; OR a Doctoral degree. Reference: VA Regulations, specifically VA Handbook 5005, Part II, Appendix G-6 Nurse Qualification Standard. This can be found in the local Human Resources Office.
The incumbent must be able to perform all activities of the position without restriction.
This position involves standing, walking, stooping, bending, reaching, lifting and turning. It may require assisting with transferring patients to/from wheelchairs to exam tables during visits. Mechanical devices, when available, are required to be used for heavy or difficult to lift patients.
The position requires visual and auditory acuity at a level to provide safe and effective nursing care. The position also requires considerable computer and telephone work while sitting or standing, and requires the nurse to work for periods of time with arms and hands at a computer and on the telephone. The position requires a considerable amount of sitting during patient consultation and typing when entering clinical notes, looking up lab results and other information.
IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.
Note: Only education or degrees recognized by the U.S.
Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: . 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: .
Annual leave shall accrue for full-time Nurses, and Nurse Anesthetists at the rate of 8 hours for each full biweekly pay period.
This job opportunity announcement may be used to fill additional vacancies.
It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.
This position is in the Excepted Service and does not confer competitive status.
United States Citizenship Required; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
VA encourages persons with disabilities to apply. The health related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority.
Veterans and Transitioning Service Members: Please visit the site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.
If you are unable to apply online view the following link for information regarding an .
How You Will Be Evaluated
You will be evaluated for this job based on how well you meet the qualifications above.
IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, rsum, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.
NOTE: Candidate's education and length of nursing practice (experience) will be considered by a Nurse Professional Standards Board in determining the grade and salary of the applicant selected. The recommended salary may be at any point in the range listed for this vacancy.
Experience as an RN will be evaluated to determine if the experience is of an acceptable level of quality with regard to the following four dimensions of nursing: Practice, Professional Development, Collaboration and Scientific Inquiry. Each dimension of practice has criteria that demonstrate essential core competencies for VHA Nursing Personnel.
Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.
Background checks and security clearance
Drug test required
To apply for this position, you must provide a complete Application Package which includes:
Only selected applicant is required to complete this form. VA Form 10-2850a - Application for Nurses and Nurse Anesthetists can be found at: .
The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this to ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's, etc.
Other Veterans Document
If you are relying on your education to meet qualification requirements:
Education must be accredited by an accrediting institution recognized by the U.S.
Department of Education in order for it to be credited towards qualifications. Therefore, provide only the attendance and/or degrees from .
Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.
This job originated on . For the full announcement and to apply, visit . Only resumes submitted according to the instructions on the job announcement listed at will be considered.
Veterans Affairs, Veterans Health Administration