Registered Nurse (Outpatient Primary Care)

The Patient Aligned Care Team (PACT) Registered Nurse will execute position responsibilities that demonstrate leadership, experience and creative approaches to management of complex patient care beyond the immediate practice setting. The Registered Nurse will demonstrate expertise in professional nursing practice to provide nursing care and care coordination within the Primary Care PACT and improve outcomes beyond the immediate practice setting.

https://youtu.be/LM35k1p_3Tc?si=6wdZw0Lag331XBMR Major Duties: Duties and responsibilities include, but are not limited to, the following: Care Coordination & Transition Management: Provide expertise in primary care coordination for the PACT Oversee transitions of care Develop and implement Veteran-centered nursing care Deliver preventive and chronic disease management interventions Provide care through multiple modalities including face-to-face visits, virtual encounters, secure messaging, and telephone-based service Utilize population health tools and evidence-based guidelines to identify and manage high-risk and chronically ill patients to improve quality of care and resource utilization at the expert level with improved outcomes beyond the immediate practice setting Collaborate with interdisciplinary team members, at the expert level, to apply structured appointments grids, and engage in proactive panel management to optimize health outcomes, support self-management, and reduce avoidable complications Patient Care/Customer Service: Provide proactive, evidence-based care management using clinical reminders, policy orders/nurse protocols, and population health tools, deliver chronic disease management, preventive health services, patient education, and health coaching to support Veteran-centered goals across all stages of care Coordinate same day needs and post discharge transitions by managing procedures, labs, follow-up, pre-visit preparation, clinical reminders, and referrals Ensure Veterans are connected with appropriate services, specialty care, and interdisciplinary team resources Demonstrate expertise in identifying and managing patients requiring RN care through daily huddles and team collaboration Develop individualized care Provide health coaching and motivational interviewing Deliver ongoing management for patients with chronic and ambulatory care-sensitive conditions resulting in improved evidence-based and/or data-driven outcomes beyond the immediate practice setting Population Identification: Lead initiatives to improve data driven outcomes by using data-driven risk indicators to identify rising-and high-risk patients Prioritize focused panel management Coordinate appropriate referrals for enhanced care management sharing best practices/improvements beyond the immediate practice setting Stratification: Use nursing expertise to identify gaps in care and connect patients with wraparound services Coordinate care and ensure smooth transitions between acute and ambulatory settings for patients with chronic diseases, population health, post discharge or acute needs Lead process improvement or quality improvement initiatives to improve processes or patient outcomes beyond the immediate practice setting Deliver ongoing RN-led chronic disease management using Veterans Affairs/Department of Defense clinical guidelines, evidence-based guidelines, health coaching, and collaboration with extended team members to support patient self-management, goal setting, and optimized clinical outcomes Team Support and Teamwork: Collaborate with PACT core team members and the extended care support team to reach PACT goals related to access, continuity, patient experience, and quality outcomes through huddles, pre-planning, and daily communication to support access, continuity, quality, and patient experience while facilitating efficient, patient-ready visits Apply Whole Health principles and appropriate task delegation to strengthen team functioning, enhance care coordination, and meet PACT performance goals Monitor team metrics and use VHA panel-management tools to identify care gaps, improve patient data, and lead proactive, high-quality primary care delivery with positive impact beyond the immediate practice setting 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 from 8:00AM - 4:30PM Telework: Available (NOTE: The Veterans Health Administration, including VA Salt Lake City Health Care System, will comply fully with the intention and instructions contained in the "Return to Office" Executive Order. This position will likely be eligible to telework on a limited Ad-Hoc basis only) Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. Selective Service Registration is required for males born after 12/31/1959. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical evaluation/examination. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). You may be required to serve a probationary period. Complete all application requirements detailed in the "Required Documents" section of this announcement.