Registered Nurse - Patient Aligned Care Team

Join the Black Hills VA Health Care System in Hot Springs, 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.

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.