Nurse Practitioner – Transitional Clinic, PRN

Job Description

Under general supervision of the CARE Center Medical Director and in collaboration with the Director of Population Health, responsible for diagnosing and treating patients subject to the individuals’ written agreement approved by the Maryland Joint Committee on Nurse Practitioners.  Provides continuity of patient care by facilitating and coordinating communication between the health care team, patient and patients’ family.   Coordinates care to ensure quality, effective care and patient safety.  Serves as link to integrating relevant services both internal and community-based consistent with the Institute for Healthcare Improvement’s Triple Aim of Better Health, Better Care, and Lower Cost. 

1. Provide appropriate care to all patients including patient history, physical examination, ordering and interpreting clinical testing, developing patient treatment plans, referral to alternate care setting or clinicians as appropriate. Promote preventative health and track gaps in care. Assess patient for potential risk factors. Recognize and integrate patient special needs and individualizes care using an interdisciplinary approach. Integrate pain management and supportive care issues in the plan of care as appropriate.

1. Maintain accurate medical records using the approved EMR system. Comply with policies and procedures and customer service metrics.

1. Take calls from patients and providers and provide appropriate information to assist in the expedited delivery of services. Assist patients with the understanding of their condition with a goal of patient self-management.

1. In conjunction with the Medical Director and administrative AVP lead a team-based approach to care that fosters mentorship, education, etc.  The team may be comprised of RN Care managers, Social Workers, Behavioral Health Workers, Medical Assistants and/or other clinical professionals.

1. Ensure that services are provided in the most cost effective manner and clinically appropriate setting to limit the avoidable utilization in the hospital. Participate in readmission reduction initiatives and strategies to reduce hospital utilization.

1. Use an interdisciplinary team approach to ensure comprehensive care delivery across the continuum to meet the needs of the patient and family through assessment and evaluation of actual and emerging patient and/or significant other’s physical, educational and emotional needs.  Maintain communication with Medical Director and other clinicians to ensure highly coordinated and efficient care. In conjunction with care team, conduct periodic review of medical records to determine efficiency of care and ensure that all care delivered is appropriate.

1. Maintain a high profile with the medical staff by working closely with the Comprehensive CARE Center Medical Director and independently with physicians, as appropriate, to ensure that physicians’ and hospitals needs are being met for cost effective quality care. Communicate regularly with the medical staff and community providers to ensure patients have timely access to care and efficient care coordination.

1. In conjunction with care team, conduct periodic review of medical records to determine efficiency of care and ensure that all care delivered is appropriate. Actively participate in workgroups and/or committees within the Comprehensive CARE center, Population Health, and UCHS that align with the hospital and department goals.

1. Comply with all provider requirements within the scope of practice:: Perform complete, focused history and physical as needed. Order appropriate diagnostic studies. Consult with Medical Director, CARE Center to determine appropriate medical management and follow-up. Complete treatment orders as needed within scope of practice. Respond in an emergency situation, initiate care until physician or 911 response arrives

1. Seek opportunities for professional growth: Attain continuing education programs relevant to areas of practice and licensure. Maintain knowledge of current literature and research applicable to practice.

1. Comply with all billing requirements of the CARE Center.

1. Demonstrate professionalism; competence and open communication style; high integrity; energy, creativity, diplomacy, and flexibility.     

1. Lead by example; maintain high personal standards for patient, family and provider satisfaction.

1. Perform other duties as assigned.