Registered Nurse - Patient Aligned Team Care Manger

PACT Registered Nurse Case Manager

The PACT Registered Nurse Case Manager serves as the primary coordinator of care for an assigned patient panel, providing comprehensive, patient-centered nursing care focused on health promotion, chronic disease management, patient education, self-management, care coordination, and customer satisfaction. Using evidence-based practice, clinical guidelines, nursing knowledge, and standardized protocols, the RNCM leads proactive care delivery to improve patient outcomes and wellness.

The RNCM collaborates with PACT team members, interdisciplinary partners, extended care support teams, and community resources to develop and implement Veteran-driven care plans, coordinate transitions of care, and ensure timely access to appropriate healthcare services. Care is delivered through multiple modalities, including face-to-face visits, virtual care, secure messaging, and telephone encounters.

Key responsibilities include identifying and managing high-risk and chronically ill patients through population health tools, panel management, daily huddles, health coaching, motivational interviewing, chronic disease management, preventive care, and patient/family education. The RNCM coordinates same-day care needs, post-discharge follow-up, referrals, laboratory and diagnostic services, and specialty care to ensure continuity and quality of care.

The RNCM monitors care gaps, utilizes data-driven risk stratification to prioritize interventions, coordinates wraparound services, and supports smooth transitions across care settings. Additionally, the RNCM promotes collaborative team-based care, applies Whole Health principles, monitors panel and performance metrics, supports quality improvement initiatives, and facilitates efficient, patient-ready visits.

The RNCM demonstrates leadership in professional nursing practice through the integration of evidence-based care, quality improvement, resource stewardship, and advocacy for patient needs while adhering to all applicable nursing licensure and Nurse Practice Act requirements.

Key Functions

• Coordinate and manage care for an assigned patient panel.
• Lead chronic disease management, preventive care, and health promotion efforts.
• Identify and manage high-risk patients using population health and panel management tools.
• Coordinate care transitions, post-discharge follow-up, referrals, and specialty care services.
• Provide patient and family education, health coaching, and self-management support.
• Collaborate with interdisciplinary teams to improve access, continuity, quality, and patient experience.
• Monitor performance metrics, address care gaps, and support quality improvement initiatives.
• Promote Veteran-centered, Whole Health care and optimize clinical outcomes through evidence-based 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: 8am to 4:30pm

Telework: Not available

Virtual: This is not a virtual position.

Relocation/Recruitment Incentives: Not authorized.

Permanent Change of Station (PCS): Not authorized.