Registered Nurse - Home Based Primary Care Nurse Case Manager

Summary

Join the Sioux Falls VA Health Care System in Union County, South Dakota, as a Home Based Primary Care Nurse Case Manager and bring comprehensive care directly to Veterans in their homes. You will assess complex health needs, provide skilled nursing care, coordinate services with VA and community partners, support Veterans and caregivers, and build lasting relationships that promote safety, independence, and quality of life.

Duties

Make a lasting difference by caring for Veterans where they are most comfortable-their homes and communities. As a Home Based Primary Care Nurse Case Manager, you will serve as a trusted advocate and clinical partner for Veterans with complex, ongoing health needs. Working closely with an interdisciplinary team, you will combine skilled nursing, care coordination, education, and problem-solving to create individualized plans that reflect each Veteran's health goals, living environment, family dynamics, and personal values. This role offers the opportunity to develop meaningful long-term relationships, strengthen continuity of care, and help Veterans remain safe and independent at home. Duties include, but are not limited to: - Conduct comprehensive in-home nursing assessments and reassessments that address each Veteran's clinical needs, living conditions, support system, and personal goals. - Develop, implement, and evaluate individualized plans of care in collaboration with Veterans, caregivers, and the Home Based Primary Care interdisciplinary team. - Provide direct nursing care in the home, including medication review, vital-sign monitoring, wound care, and other services within the registered nurse scope of practice. - Coordinate health care services across VA programs, community providers, and state and federal agencies to promote continuity, safety, and timely access to care. - Manage an assigned caseload through ongoing monitoring, follow-up, clinical judgment, and adjustment of care strategies as Veteran needs change. - Advocate for Veterans by clarifying treatment options, supporting informed decisions, resolving care barriers, and communicating concerns to the interdisciplinary team. - Educate Veterans and caregivers about health conditions, medications, self-management strategies, and available resources that support independence at home. - Travel to Veterans' residences across the assigned geographic area and provide flexible visit coverage to meet patient care and program 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: ADHOC-May be authorized (Employee 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 Travel Requirements: - You may be expected to travel 75% of the time for this position to various care locations within the service area, including Veteran homes as part of Home Health care delivery. - You must possess and maintain a current, valid, unrestricted state-issued driver's license. - You must provide a safe, clean driving record from the Department of Motor Vehicles (DMV) during onboarding. - You must successfully complete a driver's physical examination to demonstrate medical ability to safely operate a government-owned or leased vehicle, as required under 5 CFR 930 and HR Job Aid 05-OB-010.002. 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.

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/13081392. Grade/Level Scope Education Nurse I, Level I Delivers fundamental, knowledge-based care to assigned clients while developing technical competencies. An Associate Degree (ADN)