Registered Nurse - Patient Aligned Care Team

Patient Aligned Care Team Registered Nurse Care Manager

Help make a meaningful impact on Veterans' health as a Patient Aligned Care Team Registered Nurse Care Manager in Rapid City. In this collaborative primary care role, you will help Veterans navigate their care, manage chronic conditions, achieve personal health goals, and successfully transition between care settings. Working closely with core and extended team members, you will use evidence-based practices, population health tools, education, and health coaching to identify needs early and connect Veterans with the right resources. This position offers the opportunity to build lasting relationships with Veterans while advancing coordinated, proactive care that improves access, continuity, wellness, and clinical outcomes.

Duties include, but are not limited to:

• Coordinate comprehensive primary care for a designated panel of Veterans, supporting continuity, timely access, and individualized health goals.
• Deliver preventive and chronic disease management through face-to-face visits, virtual encounters, secure messaging, and telephone-based care.
• Identify rising-risk, high-risk, and chronically ill Veterans using population health tools and data-driven indicators to support proactive care management.
• Facilitate safe, coordinated transitions between acute and ambulatory settings, including post-discharge follow-up and connection to needed services.
• Provide individualized health coaching, motivational interviewing, patient education, and self-management support to help Veterans improve and maintain their health.
• Collaborate with core and extended care team members through daily huddles, pre-visit planning, and ongoing communication to address patient needs and care gaps.
• Coordinate same-day care needs, procedures, laboratory services, referrals, clinical reminders, and specialty care connections to promote efficient, patient-ready visits.
• Apply evidence-based clinical guidelines and nursing protocols to support chronic disease management, goal setting, wellness, and improved clinical 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 7:30am - 4:00pm

Telework: Ad hoc may be authorized. (Employees who telework on an occasional, episodic, or short-term, and have completed required telework training and telework agreement)

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.