Registered Nurse - Patient Aligned Care Team

Patient Aligned Care Team Registered Nurse Care ManagerMake a meaningful impact on the health and well-being of Veterans as a Patient Aligned Care Team Registered Nurse Care Manager at VA Black Hills Health Care System. This rewarding outpatient primary care position offers the opportunity to build lasting relationships with Veterans while helping them navigate their healthcare needs, manage chronic conditions, and achieve their personal health goals. As an essential member of a collaborative healthcare team, you'll connect Veterans with the resources, education, and support they need to take an active role in their health. Through proactive care coordination, evidence-based nursing practices, and a commitment to whole-person wellness, you'll help improve health outcomes, strengthen continuity of care, and enhance the overall Veteran experience. Join a mission-driven team where your nursing expertise, compassion, and dedication contribute to delivering exceptional care to those who have served our nation.Duties include, but are not limited to:Coordinate comprehensive, Veteran-centered primary care for an assigned panel of patients, ensuring timely access to services, continuity of care, and individualized support throughout their healthcare journey.Deliver proactive chronic disease management and preventive healthcare interventions using evidence-based guidelines to improve health outcomes, reduce complications, and promote long-term wellness.Facilitate seamless transitions between hospital, outpatient, and specialty care settings by coordinating post-discharge follow-up, referrals, diagnostic testing, and essential healthcare resources.Provide individualized patient education, health coaching, and motivational interviewing to empower Veterans to manage chronic conditions, establish achievable health goals, and make informed healthcare decisions.Collaborate with primary care providers, interdisciplinary team members, and extended healthcare services to develop coordinated care approaches that address Veterans' medical, preventive, and wellness needs.Identify Veterans with complex or high-risk healthcare needs using population health tools, clinical indicators, and proactive panel management strategies to prioritize interventions and close gaps in care.Deliver accessible nursing care through in-person appointments, virtual visits, telephone consultations, and secure messaging to address healthcare concerns, support treatment plans, and strengthen patient engagement.Participate in daily team huddles, pre-visit planning, and coordinated care activities to address same-day patient needs, streamline healthcare delivery, and improve access, quality, and the overall Veteran experience.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, 7:30am - 4:00pmTelework: Not AvailableVirtual: This is not a virtual position.Relocation/Recruitment Incentives: Not AuthorizedPermanent Change of Station (PCS): Not AuthorizedThe 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.