This position is eligible for the Education Debt Reduction Program (EDRP), a student loan payment reimbursement program. You must meet specific eligibility requirements per VHA policy and submit your EDRP application within four months of appointment. Program Approval, award amount (up to $200,000) & eligibility period (one to five years) are determined by the VHA Education Loan Repayment Services program office after review of the EDRP application. Former EDRP participants ineligible to apply. This Registered Nurse (Outpatient Primary Care) position is located in the Primary Care Services at the Greenfield, MA location. This position is full time at 40 hours per week. NOTE: The 2-page Resume requirement does not apply to this position. For more information, refer to Required Documents below. Duties Include but not limited to: Provides expertise in primary care coordination for the Patient Aligned Care Team (PACT), overseeing transitions of care, developing and implementing Veteran-centered nursing care, delivering preventive and chronic disease management interventions, and providing care through multiple modalities including face-to-face visits, virtual encounters, secure messaging, and telephone-based services. Utilizes 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; collaborates with interdisciplinary team members, at the expert level, to apply structured appointment grids, and engage in proactive panel management to optimize health outcomes, support self-management, and reduce avoidable complications. Provides proactive, evidence-based care management using clinical reminders, policy orders/nurse protocols, and population health tools, delivering chronic disease management, preventive health services, patient education, and health coaching to support Veteran-centered goals across all stages of care. Leads initiatives to improve Veteran/patient experience. Coordinates same day needs and post discharge transitions by managing procedures, labs, follow-up, pre-visit preparation, clinical reminders, and referrals; ensures Veterans are connected with appropriate services, specialty care, and interdisciplinary team resources. Leads initiatives to improve data driven outcomes by using data-driven risk indicators to identify rising- and high-risk patients, prioritize focused panel management, and coordinate appropriate referrals for enhanced care management sharing best practices/improvements beyond the immediate practice setting Uses nursing expertise to identify gaps in care and connect patients with wraparound services; coordinates care and ensures smooth transitions between acute and ambulatory settings for patients with chronic disease, population health, post discharge or acute needs. Leads process improvement or quality improvement initiatives to improve processes or patient outcomes beyond the immediate practice setting. Collaborates 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. Applies Whole Health principles and appropriate task delegation to strengthen team functioning, enhance care coordination, and meet PACT performance goals. Monitors team metrics and uses 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. Work Schedule: Monday - Friday 08:00 a.m. - 04:30 p.m. Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized EDRP Authorized: Former EDRP participants ineligible to apply for incentive. Contact vhaedrpprogramsupport@va.gov, the EDRP Coordinator for questions/assistance. Learn more Permanent Change of Station (PCS): Not Authorized 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 Notifications: This position is in the Excepted Service. This position is covered by a special rate. The salary is based on the grade and step approved for the selected candidate. Veterans' preference does not apply for internal or other current permanent Federal agency employees. The 2-page Resume requirement does not apply to this position. For more information, refer to Required Documents below If you are a current federal employee, you are required to attach your Most Recent non-award SF-50. This should be a SF-50 from the current calendar year which shows your current position, grade and step. Award SF-50's do not provide sufficient information and will not be accepted. VA offers a comprehensive total rewards package: VA Nurse Total Rewards 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. 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.

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