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

<p>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.</p><h3>Major Duties</h3><p>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: May be authorized for eligible, highly qualified applicants. Permanent Change of Station (PCS): Not Authorized</p><h3>Requirements</h3>U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. Selective Service Registration is required for males born after 12/31/1959. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical examination. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). You may be required to serve a probationary period. Complete all application requirements detailed in the "Required Documents" section of this announcement.