Registered Nurse Care Manager

Job TitleNursing Care Team MemberMajor Duties Include, But Are Not Limited To:Self-directed in functioning as a team member providing comprehensive, coordinated nursing care to panels of patients with occasional supervision.Focuses on proactive, patient-centered care by using nursing knowledge, evidence-based guidelines, and standardized nursing protocols.Manages care coordination for a designated panel of patients, emphasizing health promotion, chronic care management, patient self-management support, and overall wellness.Collaborate with the PACT members, extended care support team, and external services to develop and implement holistic, patient-driven care, facilitate care transitions, and provide timely, coordinated access to health care resources.Engages in patient and family education and advocates for patients' needs to enhance patient outcomes and wellness.Demonstrates a collaborative team approach for managing patient panels, ensuring continuity and quality of care tailored to individual patient goals and needs.Connects patients with wraparound services; coordinates care and ensures smooth transitions between acute and ambulatory settings for assigned patients with chronic disease, population health, post-discharge, or acute needs.Monitors assigned PACT metrics and uses VHA panel-management tools to identify care gaps, prepare patient data, and support proactive, high-quality primary care delivery.Identifies and manages assigned patients requiring RN care through daily huddles and team collaboration; develops individualized care, provides health coaching and motivational interviewing, and delivers ongoing management for patients with chronic and ambulatory care-sensitive conditions.Self-directed in providing primary care coordination for the Patient Aligned Care Team (PACT), overseeing transitions of care, developing and implementing Veteran-centered nursing care, delivering preventive and chronic disease management interventions, and providing care through multiple modalities, including face-to-face visits, virtual encounter.This position potentially requires flexibility in schedule and assignments.All other duties as assigned.VA offers a comprehensive total rewards package: VA Nurse Total RewardsPay: Competitive salary, regular salary increases, potential for performance awardsPaid 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 VAInsurance: 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 territoryWork Schedule: Monday-Friday, 0800-1630Telework: Not AvailableVirtual: This is not a virtual position.Relocation/Recruitment Incentives: Not AuthorizedPermanent Change of Station (PCS): Not Authorized