Registered Nurse - Outpatient Primary Care (PACT)

Major Duties

Duties and responsibilities include, but are not limited to, the following:

Care Coordination & Transition Management:

• Provide expertise in primary care coordination for the Patient Aligned Care Team (PACT), oversee transitions of care, develop and implement Veteran-centered nursing care, deliver preventive and chronic disease management interventions, and provide care through multiple modalities including face-to-face visits, virtual encounters, secure messaging, and telephone-based services.
• Utilize population health tools and evidence-based guidelines to identify and manage high-risk and chronically ill patients to improve quality of care and resource utilization at the expert level with improved outcomes beyond the immediate practice setting; Collaborate with interdisciplinary team members, at the expert level, to apply structured appointment grids, and engage in proactive panel management to optimize health outcomes, support self-management, and reduce avoidable complications.

Patient Care/Customer Service:

• Provide proactive, evidence-based care management using clinical reminders, policy orders/nurse protocols, and population health tools, deliver chronic disease management, preventive health services, patient education, and health coaching to support Veteran-centered goals across all stages of care. Lead initiatives to improve Veteran/patient experience.
• Coordinate same day needs and post discharge transitions by managing procedures, labs, follow-ups, pre-visit preparation, clinical reminders, and referrals; Ensure Veterans are connected with appropriate services, specialty care, and interdisciplinary team resources.
• Demonstrate expertise in identifying and managing patients requiring RN care through daily huddle and team collaboration; develop individualized care, provide health coaching and motivational interviewing, and deliver ongoing management for patients with chronic and ambulatory care-sensitive conditions resulting in improved evidence-based and/or data-driven outcomes beyond the immediate practice setting.

Population Identification:

• Lead initiatives to improve data driven outcomes by using data-driven risk indicators to identify rising and high-risk patients, prioritize focused panel management, and coordinate appropriate referrals for enhanced care management sharing best practice/improvements beyond the immediate practice setting.

Stratification, Care Coordination & Transition Management:

• Use nursing expertise to identify gaps in care and connect patients with wraparound services; Coordinate care and ensure smooth transitions between acute and ambulatory settings for patients with chronic disease, population health, post discharge or acute needs. Lead process improvement or quality improvement initiatives to improve processes or patient outcomes beyond the immediate practice setting.
• Deliver ongoing RN-led chronic disease management using Veterans Affairs/Department of Defense clinical guidelines, evidence-based guidelines, health coaching, and collaboration with extended team members to support patient self-management, goal setting, and optimized clinical outcomes.

Team Support & Teamwork:

• Collaborate 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, pre-planning, and daily communication to support access, continuity, quality, and patient experience while facilitating efficient, patient-ready visits.
• Apply Whole Health principles and appropriate task delegation to strengthen team functioning, enhance care coordination, and meet PACT performance goals.
• Monitor team metrics and use VHA panel-management tools to identify care gaps, improve patient data, and lead proactive, high-quality primary care delivery.

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; 8:00 AM-4:30 PM

Telework: Available (Ad-Hoc)

NOTE: The Veterans Health Administration, including the Montana VA Health Care System, will comply fully with the intention and instructions contained in the "Return to Office" Executive Order. This position will likely be eligible to telework on a limited Ad-Hoc basis only)

Virtual: This is not a virtual position.

Relocation/Recruitment Incentives: Not Authorized

Permanent Change of Station (PCS): Not Authorized

US Department of Veterans Affairs