Registered Nurse - Patient Aligned Care Team (PACT) Care Manager

The Patient Aligned Care Team (PACT) Registered Nurse (RN) Care Manager will utilize the nursing process and evidence based practice to deliver and manage comprehensive care to an assigned panel of patients in a clinic setting. The RN is a key member of the PACT and multidisciplinary team and is responsible for collaboration with other team members, promoting effective communication and ethical practice. PRINCIPALES MISSIONS : The VA Midwest Health Care Network advocates for a Whole Health System of care in each of the Medical Centers. This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest. As an employee operating in a Whole Health System of care, you will operate in a model with three core elements, seeking to create a personalized health plan for each Veteran. This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community. This aligns with the Veterans Health Administration (VHA) Mission Statement to Honor America's Veterans by providing exceptional health care that improves their health and well-being. 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 The primary duties for the PACT RN Care Manager include, but are not limited to: Serve as the primary point of contact for care management and coordination for an assigned patient panel, focusing on high-risk patients, care transitions, and population health strategies utilizing data resources. Use nursing expertise, evidence-based guidelines, and standardized protocols to develop, implement, and update individualized, patient-driven care plans in collaboration with interdisciplinary teams and patients/families. Provide health education, coaching, and counseling to patients and families, emphasizing self-management, prevention, wellness, and shared decision-making. Work actively with the PACT Team, internal and external VA services, and community-based resources to assess patient needs, support care transitions, and ensure comprehensive patient care. Participate in performance improvement activities, utilize patient registries and data resources for population health management, and monitor outcomes to identify care gaps and enhance patient wellness. Maintain current knowledge of multidisciplinary resources and programs, refer patients as appropriate, and serve as a resource for navigating the healthcare system and processes. Assess patients for telehealth and home monitoring devices, utilize VA Video Connect, Document all patient interactions and interventions in the patient record, complete encounters for workload credit, and support compliance with standards and nursing practice aligned with Primary Care ICC and CAN Score management. Work Schedule: Monday through Friday; 8:00 am to 4:30 pm Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not authorized Permanent Change of Station (PCS): Not authorized QUALIFICATIONS REQUISES : Basic Requirements: English Language Proficiency. In accordance with 38 U.S.C. 7403(f), no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English. Graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited by one of the following accrediting bodies at the time the program was completed by the a

Salaire : $61,784 – $112,090/Per Year | Avantages : http://www.vacareers.va.gov/why-choose-va/benefits/index.asp

OUR MISSION: To fulfill President Lincoln's promise "To care for those who have served in our nation's military and for their families, caregivers, and survivors" - by serving and honoring the men and women who are America's Veterans. How would you like to become a part of a team providing compassionate whole health care to Veterans? The Fargo VA Health Care System (HCS) proudly holds a 5-star CMS rating and a 5-star Community Living Center (CLC) rating and is recognized as #1 in patient experience and cleanliness among Level 2 Hospitals in the VHA. As a Joint Commission accredited medical/surgical hospital, it features 36 acute care beds, a 38-bed CLC, Primary Care and Specialty Clinics, and 10 Community Based Outpatient Clinics (CBOCs) across ND and NW MN. Serving more than 36,000 Veterans in ND, 17 counties in NW MN, and one NE SD county, the Fargo VA HCS manages approximately 300,000 outpatient visits annually. They are affiliated with multiple colleges and universities to provide