Registered Nurse - Patient Aligned Care Team

Summary The Registered Nurse Care Manager (RNCM) is responsible for organizing and directing team members to achieve desirable patient outcomes through day-to-day and/or telephonic case management. The RNCM functions in the Primary Care Clinic which utilizes a Patient Aligned Care Team (PACT) model. The RNCM uses the nursing process and evidence-based practice to collaborate with the Core Team in developing the patient-driven care plan. Qualifications English Language Proficiency – in accordance with 38 U.S.C. 7403(f); proficiency in basic written and spoken English is required. Graduate of an accredited professional nursing school (ACEN or CCNE) or equivalent, including foreign graduates with recognized equivalency evaluation (e.g., ICD). Active, unrestricted state license, or qualified for temporary appointment while completing a bridge program. Graduates of foreign nursing schools: must have current full + unrestricted registration and a formal equivalency validation. Graduate Nurse Technician (GNT) exception: candidates who meet basic education but lack licensure may be appointed at the entry step on a 120-day temporary appointment, extendable up to two years. Grade determinations and scope criteria vary by level (Nurse I‑III, BSN, ADN, MSN, Doctoral). Detailed requirements are available through the VA Staffing questionnaire. Preferred experience: Primary Care Case Management (more information available at the VA Qualification Standards reference). Duties Demonstrate clinical knowledge in assessing, planning, implementing, documenting, and evaluating care for a designated group of patients. Triage and apply a collaborative team approach to identify, analyze, and resolve patient-care problems. Collaborate with patients to assess needs, identify issues, set care goals, and determine resources for discharge, post-hospital recovery, and health maintenance. Maintain current knowledge of multidisciplinary resources and refer patients to community resources as appropriate. Utilize problem-solving methodologies to advance clinical knowledge and resolve system/process issues that impact patient care. Assist patients with navigating health systems and intervene or refer as needed to facilitate outcome achievement. Provide culturally respectful care aligned with patients’ personal values. Assist in developing, assessing, and monitoring comprehensive care plans that promote efficient, effective, and coordinated care. Coordinate an interdisciplinary approach to meet physical, psycho-social, and environmental needs. Benefits VA offers a comprehensive total rewards package: Competitive salary with regular raises and potential performance awards. Paid Time Off: 50 days per year (26 days annual leave, 13 days sick leave, 11 federal holidays). Retirement: Traditional federal pension (5-year vesting) plus federal 401(k) with up to 5% employer match. Insurance: Federal health, vision, dental, term life, long-term care (many plans can be carried into retirement). Licensure: Requires 1 full, unrestricted license from any U.S. state, territory, or Commonwealth. Work schedule: Monday-Friday, 7:30 am–4:00 pm. Telework: Ad Hoc only, at the discretion of the hiring manager. This is not a virtual position. Relocation/Recruitment Incentives: Not authorized. Permanent Change of Station (PCS): Not authorized. #J-18808-Ljbffr