The ideal candidate is passionate about whole-person care and demonstrates strong skills in patient engagement, care coordination, chronic disease management, and collaboration with behavioral health providers.
What You'll Do
ESSENTIAL DUTIES AND RESPONSIBILITIES
Clinical Nursing Responsibilities
Perform patient intake, rooming, and visit preparation.
Obtain and document vital signs, height, weight, BMI, tobacco use status, and relevant health information.
Administer immunizations, injections, medications, and point-of-care testing per provider orders and scope of practice.
Perform specimen collection, EKGs, hearing and vision screening, and other clinical support services as assigned.
Assist providers with examinations, procedures, and treatment plans.
Conduct medication reconciliation and review medication adherence.
Document patient encounters accurately and timely within the Electronic Health Record (EHR).
Monitor and communicate abnormal findings to providers promptly.
Participate in daily huddles and interdisciplinary care team meetings.
Provide patient education related to chronic disease management, preventive care, medications, nutrition, lifestyle modification, and treatment adherence.
Care Coordination Responsibilities
Identify high-risk patients requiring enhanced care management services.
Coordinate referrals to specialists, diagnostic testing, community agencies, and social service organizations.
Track referral completion and follow up on outstanding appointments and results.
Conduct outreach to patients following emergency department visits, hospitalizations, and psychiatric admissions.
Assist patients in scheduling appointments and overcoming barriers to care.
Collaborate with behavioral health providers to develop integrated care plans.
Support transitions of care and ensure continuity between healthcare settings.
Monitor patients with chronic conditions such as diabetes, hypertension, obesity, COPD, asthma, hyperlipidemia, and other chronic diseases.
Assist in closing preventive care gaps including annual wellness visits, immunizations, cancer screenings, and chronic disease monitoring.
Coordinate social determinants of health interventions and connect patients with housing, food, transportation, financial assistance, and other community resources.
