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.
Exhibits leadership in promoting proactive and evidence-based care by bringing up to date research and data to the team and leading process improvements to keep team practices current.
Participates in chronic disease management for panel in collaboration with provider. Engages in Shared Medical Appointments (SMA), Group visits, Team visits 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.
Participates in Tele Primary Care Serves in a role to support Telehealth clinical programs across the system.
Exhibits leadership in promoting proactive and evidence-based care by bringing research and data to the team and leading process improvements to keep team practices current.
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.
Supports patient self-management by providing an ongoing relationship with the PACT with current information regarding all options, choices, and resources.
Work Schedule: Monday thru Friday, 8am - 4:30pm
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
Basic Requirements :
United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
Graduate of a school of professional nursing approved by the appropriate State-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 ). In cases of graduates of foreign schools of professional nursing, possession of current, full, active and unrestricted registration will meet the requirement of graduation from an approved school of professional nursing. OR The completion of coursework equivalent to a nursing degree in a MSN Bridge Program that qualifies for professional nursing registration constitutes the completion of an approved course of study of professional nursing. Students should submit the certificate of professional nursing to sit for the NCLEX to the VA along with a copy of the MSN transcript. (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.
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.
BSN and/or Master's degree from an accredited school of nursing recognized by the VA (Commission on Collegiate Nursing Education (CCNE) or The Accreditation Commission for Education in Nursing (ACEN).
Two years of successful nursing practice in acute / critical / MSU within the last 5 years
Lean Principles Training. (Belt).
Current proficiency in Basic Life Support (BLS) through the American Heart Association (Required prior to assuming clinical duties and must remain current -VHA Directive 11-77)
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.
Involves considerable amount of standing, walking, stooping, bending, reaching, lifting, and turning.
Requires carrying or lifting of objects weighing up to 50 lbs., but occasionally may require work that involves pushing or lifting in excess of 50 pounds and going up and down flights of stairs.
The position requires visual and auditory acuity at a level to provide safe and effective nursing care.
The position requires the nurse to work for periods of time with arms above shoulder level or with neck in a fully flexed or extended position and the ability to physically control or defend against emotionally ill clients.
Requires use of hands for actions such as typing, simple grasping, fine manipulation, and repetitive actions.
Requires the ability to frequently respond to multiple demands and priorities.
Has potential for exposure to infectious diseases, hazardous waste and chemicals.
Ability to distinguish shades of colors
Ability to effectively utilize a stethoscope and distinguish breath and heart, and bowel sounds;
Emotional and mental stability - ability to effectively perform the essential functions of the position and respond appropriately in emergency situations.
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: http://ope.ed.gov/accreditation/ . 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 .
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 VA for Vets 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 Alternate Application .
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, résumé, 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:
VA Form 10-2850a - Application for Nurses and Nurse Anesthetists can be found at: http://www.va.gov/vaforms/search_action.asp?FormNo=2850&tkey=&Action=Search . REQUIRED AND MUST BE CURRENT AS OF LAST 12 MONTHS.
The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist 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.
Service Connected Disability Letter
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 schools accredited by accrediting institutions recognized by the U.S. Department of Education .
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.
A career with the U.S. Government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Learn more about federal benefits .
Review our benefits
Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time, or intermittent. Contact the hiring agency for more information on the specific benefits offered.