Registered Nurse - Patient Aligned Care Team Care Manager

Summary

The Patient Aligned Care Team (PACT) Registered Nurse Care Manager (RNCM): Outpatient Primary Care (PC) demonstrates proficiency in practice providing nursing care and care coordination based on conscious and deliberate planning within the Primary Care PACT. The PACT RNCM is self-directed in functioning as a team member providing comprehensive, coordinated nursing care to panels of patients with occasional supervision.

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This job is open to

The public

U. S. Citizens, Nationals or those who owe allegiance to the U. S.

Internal to an agency

Current federal employees of the hiring agency that posted the job announcement.

Clarification from the agency

NOTE: The 2-page Resume requirement does not apply to this position. First area of consideration will be given to current permanent employees of the Altoona VA Medical Center and Agency Employees. Second area of consideration will be given to all others.

Duties

Responsibilities include, but are not limited to the following

• Provides 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 encounters, secure messaging, and telephone-based services.

• Utilizes population health tools and evidence-based guidelines to identify and manage high-risk and chronically ill patients; collaborates with interdisciplinary team members, applies structured appointment grids, and engages in panel management to optimize health outcomes, support self-management, and reduce avoidable complications.

• Provides proactive, evidence-based care management using clinical reminders, policy orders/nurse protocols, and population-health tools, delivering chronic disease management, preventive health services, patient education, and health coaching to support Veteran-centered goals across all stages of care and improve outcomes for the immediate practice setting.

• Coordinates same-day needs and post-discharge transitions by managing procedures, labs, follow-up, pre-visit preparation, clinical reminders, and referrals; ensures Veterans are connected with appropriate services, specialty care, and interdisciplinary team resources.

• Identifies and manages patients requiring RN care through daily huddles and team collaboration; individualized care, health coaching and motivational interviewing, and delivers ongoing management for patients with chronic and ambulatory care sensitive conditions.

• Identifies and manages patients requiring RN care through daily huddles and team collaboration; provides individualized care, health coaching and motivational interviewing, and delivers ongoing management for patients with chronic and ambulatory care sensitive conditions.

• Delivers ongoing RN led chronic disease management using Veterans Affairs/Department of Defense (VA/DOD) clinical guidelines, evidence-based guidelines, health coaching, and collaboration with extended team members to support patient self-management, goal setting, and optimized clinical outcomes

• Collaborates 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, preplanning, and daily communication to support access, continuity, quality, and patient experience while facilitating efficient, patient ready visits

• Applies Whole Health principles and appropriate task delegation to strengthen team functioning, enhance care coordination, and meet PACT performance goals.

• Monitors team metrics and uses VHA panel management tools to identify care gaps, prepare patient data, and support 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

M-f- 7:00am- 3:30pm

Compressed/Flexible: Not Available Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS) : Not Authorized

Requirements

Conditions of employment

• U. S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.

• All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA.

• Selective Service Registration is required for males born after 12/31/1959.

• Subject to background/security investigation.

• Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.

• Must pass pre-employment physical evaluation/examination.

• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).

• You may be required to serve a probationary period.

• Complete all application requirements detailed in the "Required Documents" section of this announcement.

Qualifications

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 applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE); OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program. Upon achievement of a State license, the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program. (Reference VA Handbook 5005, Appendix G6); OR In cases of graduates of foreign schools of professional nursing, possession of a current, full, active, and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program. Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD).

• Current, full, active, and unrestricted registration as a graduate professional nurse in a State, Territory or Commonwealth (i.e., Puerto Rico) of the United States, or the District of Columbia. Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements, but do not possess the required licensure, may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.)

NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification.

Grade Determinations: The following Scope, Education and Dimension criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade. The Dimension requirements (Practice, Veteran/Patient Driven Care, Leadership, Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: https://apply.usastaffing.gov/ViewQuestionnaire/13078723.

Grade/Level

Scope

Education

Nurse I, Level I

Delivers fundamental, knowledge-based care to assigned clients while developing technical competencies.

An Associate Degree (ADN) or Diploma in Nursing, with no additional professional nursing required.

Nurse I, Level II

Demonstrates integration of biopsychosocial concepts, cognitive skills and technically competent practice in providing care to clients with basic or complex.

An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I, Level 1 ; OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required.

Nurse I, Level III

Demonstrates proficiency in practice based on conscious and deliberate planning. Self-directed in goal setting for managing complex client situations.

An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I, Level 2; OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I, Level 2; OR a Master's degree in nursing (MSN) and no additional professional nursing experience; OR a Master's degree in a *related field with a BSN and no additional professional nursing experience.

Nurse II

Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others.

A BSN with 2 years of professional nursing equivalent to Nurse I, Level 3; OR an MSN with one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Master's degree in a related field with a BSN and one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Doctoral degree in Nursing with no professional nursing experience; OR a Doctoral degree in a related field with a BSN with no additional professional nursing experience.

Nurse III

Executes position responsibilities that demonstrate leadership, experience and creative approaches to management of complex client care beyond the immediate practice setting.

MSN and 2 years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Master's degree in related field with BSN and two years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in a related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III.

• Note: Foreign education programs/degrees are not creditable as related degrees.

Preferred

Experience

2 years of either primary care, care management,…