Registered Nurse - Patient Aligned Care Team

Diversity Group; Rapid City (SD); On-site; USD 90,000 - 110,000; Full time

Job summary

Black Hills VA Health Care System in Rapid City, SD seeks a Patient Aligned Care Team Registered Nurse Care Manager to coordinate Veteran-centered primary care, manage chronic conditions, and support transitions across care settings.

The role emphasizes health coaching, family education, and collaboration with an interdisciplinary team to meet each Veteran's goals and improve health outcomes.

Qualifications

• English proficiency as required by VA policy.
• Graduate of an approved nursing program with active RN licensure.
• State licensure upon appointment and eligibility for GNT exception as applicable.

Responsibilities

• Coordinate comprehensive, Veteran-centered primary care for an assigned panel.
• Manage chronic and ambulatory care-sensitive conditions with evidence-based interventions.
• Facilitate safe transitions between inpatient, outpatient, and community settings.

Skills

English proficiency

Care coordination

Interdisciplinary teamwork

Health coaching

Education

RN license (state)

Nursing degree (ADN/BSN)

Job description

Summary

Join the Black Hills VA Health Care System in Rapid City - South Dakota - as a Patient Aligned Care Team Registered Nurse Care Manager and help Veterans achieve healthier - more independent lives. You will coordinate care - manage chronic conditions - support care transitions - provide health coaching - and collaborate with an interdisciplinary team to deliver personalized primary care centered on each Veteran's goals.

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/13070586
• 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: Primary Care experience preferred - not required BSN experience preferred - not required Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• Physical Requirements: You may be asked to participate in a pre-employment examination or evaluation as part of the pre-employment process for this position
• Questions about physical demands or environmental factors may be addressed at the time of examination/evaluation.

Duties

• Build a meaningful nursing career while helping Veterans navigate their health care with confidence
• As a Patient Aligned Care Team Registered Nurse Care Manager - you will serve as a trusted clinical partner for a designated panel of Veterans - connecting them with preventive care - chronic disease support - education - and essential health care resources
• Working alongside primary care providers - extended care professionals - and community partners - you will strengthen continuity - close care gaps - and promote informed self-management while making a lasting difference in the health and well-being of Veterans
• Duties include - but are not limited to: Coordinate comprehensive - Veteran-centered primary care for an assigned patient panel - supporting timely access - continuity - and individualized health goals
• Manage chronic and ambulatory care-sensitive conditions through evidence-based interventions - ongoing follow-up - and collaboration with primary and specialty care teams
• Facilitate safe transitions between inpatient - outpatient - and community settings by coordinating post-discharge care - referrals - laboratory services - procedures - and follow-up needs
• Deliver nursing care through in-person visits - virtual appointments - secure messaging - and telephone encounters to provide Veterans with flexible access to support
• Identify rising-risk - high-risk - and chronically ill Veterans using population health tools - clinical indicators - and panel-management data to prioritize care needs
• Educate Veterans and their families through health coaching - motivational interviewing - goal setting - and personalized self-management support
• Collaborate with PACT members and extended care teams through daily huddles - pre-visit planning - and ongoing communication to improve care coordination and patient-ready visits
• Connect Veterans with specialty care - wraparound services - and interdisciplinary resources that address preventive - acute - chronic - and post-discharge health needs
• 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: Not Available 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.