Relocation Expenses: Relocation expenses are not
authorized for this position.
1. Demonstrates advanced clinical knowledge in assessing, planning, implementing, documenting, and evaluating care for a panel of patients across the continuum of care, recognizing the age related cognitive, physical, emotional, and chronological maturation needs of the adult and geriatric patient.
2. Exhibits leadership in promoting proactive and
evidence-based care by bringing up to date research and data to the team and
leading process improvements to keep team practices current.
3. Participates in chronic disease management for panel in
collaboration with provider. Engages in Shared Medical Appointments (SMA),
Group visits, Team visits and/or RNCM visits.
4. Utilizes the Primary Care Almanac and PACT Metrics to
address population health management issues and improve Team processes.
5. Triages and applies a collaborative team approach in
identifying, analyzing, and resolving patient care problems.
6. Assists in determining appropriate scheduling based on
patient's clinical need. Right person, right place, right time
7. Collaborates with ancillary team members and resources
within the clinic to manage clinic access issues. This may include assisting
other nursing staff with maintaining clinic flow.
8. Exhibits leadership in promoting proactive and
evidence-based care by bringing research and data to the team and leading
process improvements to keep team practices current.
9. Promotes patient, family and team interactions, and problem
solving by actively participating in interdisciplinary meetings to facilitate
coordination and the achievement of identified goals.
10. Retains current knowledge of multidisciplinary resources,
programs, and services, referring patients for community resources as
appropriate. Demonstrates ability to collaborate and coordinate with all levels
of services and disciplines.
11. Collaborate with patients to assess and identify needs,
issues, care goals, and resources for achieving desired outcomes post hospital
recovery and health maintenance/wellness by effectively using Motivational
Interviewing and TEACH techniques.
12. Supports patient self-management by providing an ongoing
relationship with the PACT with current information regarding all options,
choices, and resources. Provides patient centered care while respecting
patient's personal values, cultural, and belief system.