Registered Nurse (RN) Care Manager

This position is contingent upon award:

The Registered Nurse (RN) Care Manager functions as the primary RN within a Patient Aligned Care Team (PACT) at a VA Community Based Outpatient Clinic. The RN Care Manager provides proactive Veteran-centered care through care coordination clinical triage chronic disease management preventive services health coaching and population health outreach. The role emphasizes safety access quality and whole health while collaborating closely with providers LPN/MAs behavioral health pharmacy and social work to achieve optimal outcomes.

• Serve as the PACT RN for an assigned patient panel; coordinate care across visits settings and services.
• Perform RN triage (in-person/telephone/video) and implement evidence-based protocols; escalate per clinical judgment.
• Develop implement and adjust patient-centered care plans; support self-management and whole health goals.
• Coordinate referrals consults and transitions of care; ensure closed-loop follow-up and test/result tracking.
• Lead post-discharge calls and high-risk outreach to reduce readmissions and ED utilization.
• Use registries/dashboards to identify and close care gaps (immunizations screenings chronic disease control).
• Conduct risk stratification and targeted outreach (e.g. uncontrolled A1c/BP high ED use missed appointments).
• Run pre-visit planning and daily huddles; ensure needed labs imaging and referrals are completed prior to visits.
• Provide nursing interventions within scope: medication administration wound care immunizations EKGs specimen collection and patient education.
• Assist with procedures and perform nurse visits per standing orders and protocols.
• Respond to in-clinic emergencies; act as charge/lead RN as assigned.
• Adhere to VA directives nursing standards infection prevention and medication safety policies (HIPAA/Privacy OSHA CLIA as applicable).
• Participate in quality improvement (PDSA cycles) audit readiness and event reporting/resolution.
• Ensure timely accurate documentation using clinical reminders and standardized RN note templates.
• Support access targets (same-day access third-next-available) through RN-led protocols virtual care and efficient workflows.
• Reduce cycle time via in-rooming efficiency nurse-driven order sets and effective teamwork.
• Provide trauma-informed culturally competent care; participate in service recovery and SHEP/CX action plans.
• Document assessments interventions care plans and education in the VA EHR (e.g. CPRS/Cerner) in accordance with policy.
• Use population health tools to monitor outcomes and communicate trends to the team.
• Safeguard Veteran privacy and information security in all workflows.
• Completes required organizational compliance education including assigned requirements that are client-specified for Joint Commission Healthcare Staffing Services certification or other regulatory bodies.

This list is non-exhaustive and the role holder may be required to undertake additional duties
that are not specifically listed above.

Qualifications :

Required Skills and Knowledge:

• Strong clinical assessment and triage skills with sound judgment and escalation practices.
• Team-based mindset with excellent communication de-escalation teaching and motivational interviewing skills.
• Data-driven approach to panel management and quality improvement; comfortable with dashboards and registries.
• Competency in infection prevention medication management test tracking and emergency response in ambulatory settings.

Education Required:

• Current unrestricted RN license in the state where the CBOC is located; graduate of an accredited nursing program.
• BLS (AHA) required; ACLS preferred or required based on clinic scope.
• At least 2 years of recent ambulatory/primary care care management or comparable RN experience.
• Proficiency with EHRs and telehealth; ability to use clinical reminders protocols and registries.

Experience Preferred:

• BSN (preferred) or higher; relevant certifications (e.g. Ambulatory Care Nursing RN-BC CDE/CDCES CCM CHFN).
• Experience in VA/DoD CBOC FQHC or PCMH environments; familiarity with the PACT model and VA directives.
• Demonstrated success in chronic disease programs (e.g. diabetes hypertension COPD) transitions of care or womens health in primary care.

Physical Requirements:

• Sitting standing walking climbing bending/stooping kneeling twisting.
• Visual acuity. Minimal hearing loss.
• Push/pull/carry minimum 25 lbs.

Other Special Qualifications:

• Obtain medical clearance and maintain current immunizations.
• Eligibility to work in federal healthcare settings; successful background check/public trust suitability.
• Completion of required training

Additional Information :

Pay range is based on several factors and may vary in addition to a full range of medical financial and/or other benefits. Final salary and offer will be determined by the applicants background experience skills internal equity and alignment with geographical market data. 

Benefits Full-time positions are eligible for our comprehensive and competitive benefits package including medical dental vision and basic life insurance. Additional benefits include a 401k plan paid time off and an annual bonus. International SOS Government Medical Services Inc. complies with all federal state and local minimum wage laws. 

International SOS Government Medical Services Inc. is an equal opportunity employer and does not discriminate against employees or job applicants on the basis of race color religion gender sexual orientation gender identity national origin age disability genetic information marital status amnesty or status as a covered veteran in accordance with the applicable federal state and local laws. 

Remote Work :

No

Employment Type :

Full-time