• Provide professional nursing care for clinic patients following established standards and practices.
• Provide telephone triage, patient flow, and coordination of patient care.
• Schedule emergent need patient appointments, identify learning needs for patients and families, provide advice and recommendations, insert intravenous access with medication administration and duties as assigned based on clinic need.
• Delegate tasks to clinical staff in accordance with demonstrated competencies and consideration to Scope of Practice.
• Serve as subject matter expert for patient education, assessment, interpretation, and documentation of patient care and testing.
• Enter admission orders as directed by provider.
• Manage expired samples.
• Able to work in a team atmosphere as well as autonomously.
• Provide excellent customer service skills and professional demeanor at all times.
• May cover Medical Assistant, LPN, or other office duties as needed.

• Demonstrate ability to mange care within the established standards of nursing care and practice as defined by the state.
• Appropriately triage patient and prioritizes needs, displaying a caring and responsive attitude.
• Initiate care to stabilize patient and assist in managing life support needs by collaborating with physician and clinical staff, demonstrating appropriate admission, discharge and transfer procedures.
• Collect detailed patient history and symptoms, including vital signs, providing appropriate care in a timely and cost-effective manner.
• Collect laboratory samples and perform lab testing in accordance with CLIA regulations and established polices and procedures.
• Report adverse treatments or medications in accordance with current policies and procedures.
• Prepare patient meals.
• Participates in QAPI activities including participation in accreditation preparation and survey process, and maintenance of accreditation, state, and CMS standards.

• Acts as an advocate for the patient in all activities including nursing assessments, care coordination, care plan development, and communication.
• This position is accountable for identifying and developing innovative actions to meet the needs of the patient from both the health care and psychosocial / socioeconomic dimensions of care as well as acting for provision of services to meet those needs.
• Assist with completion of the initial patient assessment, including a medical record review where available
• Documentation of current advance care directive status and ongoing efforts to reconcile patient/caregiver misaligned goals with current clinical status
• Perform ongoing assessments commensurate with patient risk level and/or identified need
• Collaboration with multi-disciplinary team to develop plan of care, establishing a collaborative approach to patient needs across clinicians and care delivery
• Initiate and maintain ongoing communications with clinicians involved in patient care, especially PCP
• Meet with families/responsible parties for collaboration on patient plan of care and discussion of patient/family/responsible party contribution to the ongoing management of patient condition
• Coordinate care across the continuum of care delivery model as the point of contact for patient/caregiver and clinicians
• Act as liaison between providers, nursing facilities, hospitals and program staff, including making recommendations about care alternatives or equipment that will aide in the safety of the patient while promoting optimal clinical outcomes
• Monitor patient progress to plan of care goals with emphasis on patient care need during transitions and changes in member level of care needs
• Monitor patient during admissions to both acute and skilled level of care to support patient needs, establish as the point of contact to clinicians and patient/responsible party/families to ensure consistent and ongoing communication between all involved parties
• Main educator for patients and/or families/responsible parties on disease processes and ways to manage disease progression as independently as possible
• Reviews medical information collected including medical records and/or performs additional assessment to facilitate medical necessity determinations regarding service requests as established with in the identified program guidelines and the state established nurse scope of practice
• Serve as a resource to the entire care delivery team
• Identification and reporting of any quality of care issues
• Maintain HIPAA compliance as it relates to patient care
• Attend departmental meetings and daily huddles
• Completes other duties as assigned
• Requires 5 or more years of clinical practice in a hospital, clinic, home care or nursing home setting

• Provides in-home nursing services and patient care to Hospital in Your Home patients.
• Completes assessment of patient's physical and psychosocial status and needs.
• Responsible for working with other members of the health care team when indicated to ensure optimal patient outcomes.
• Executes orders and notifies physician and Command Center team of patient needs and changes in condition.
• Demonstrates proficiency with clinical competencies and participates in-service training and continuing education opportunities.
• Provides education and counseling to patients, family members, and other caretakers to support patient's care plan.
• Documents patient visits, interventions, assessments, educational activities, and support provided.
• Abides by legal and system rules, policies, and procedures.
• All other duties as assigned.

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