Registered Nurse - Patient Aligned Care Team

Registered Nurse Patient Aligned Care Team

Make a lasting difference in the health and well-being of Veterans as a Registered Nurse Patient Aligned Care Team at the Spirit Lake VA Clinic. In this collaborative outpatient role, you will build meaningful relationships with Veterans, coordinate care across services, and help patients manage chronic conditions, navigate transitions, and achieve personal health goals. You will work closely with primary care providers, extended team members, families, and caregivers to close care gaps, connect Veterans with essential resources, and deliver proactive care through in-person and virtual services. This opportunity offers a rewarding blend of clinical practice, care coordination, patient education, and team-based problem-solving in a setting where your nursing expertise directly strengthens access, continuity, and the Veteran experience.

Duties include, but are not limited to:

• Coordinate comprehensive, Veteran-centered primary care for an assigned patient panel, promoting continuity across outpatient, acute care, specialty, and community services.
• Deliver preventive care and ongoing chronic disease management using evidence-based guidelines, standardized nursing protocols, and individualized care plans.
• Identify Veterans with rising or high-risk needs by using population health information, clinical indicators, and panel management tools to prioritize timely interventions.
• Facilitate safe transitions of care by coordinating post-discharge follow-up, laboratory services, procedures, referrals, and connections to appropriate clinical resources.
• Provide individualized education, motivational interviewing, health coaching, and self-management support that empower Veterans to achieve meaningful health and wellness goals.
• Address routine and same-day clinical needs through face-to-face visits, virtual appointments, secure messaging, and telephone-based nursing services.
• Collaborate with primary care and extended interdisciplinary team members through daily huddles, pre-visit planning, and ongoing communication to improve access and patient-ready visits.
• Evaluate care gaps, coordinate wraparound services, and connect Veterans with specialty care and interdisciplinary resources to reduce avoidable complications and improve outcomes.

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: Monday - Friday 8:00am - 4:30pm

Telework: Not Authorized

Virtual: This is not a virtual position.

Relocation/Recruitment Incentives: Not Authorized

Permanent Change of Station (PCS): Not Authorized

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.