Care Team Nurse

Essential Functions

• Apply the Core Concepts of patient and family centered care in practice and use this knowledge to personalize care for each patient/family.
• Recognize the impact of nursing care and patient/family partnerships on patient outcomes.
• Provide the delivery of culturally sensitive age-specific nursing care for adult, pediatric, and OB/GYN patient populations in a Family Medicine setting.
• Demonstrate knowledge of and ability to competently perform technical procedures and use equipment properly.
• Delegate tasks appropriately.
• Perform telephone triage, assessment, screening, patient education and direct patient care.
• Perform accurate and expedient documentation of nursing care.
• Have knowledge and appropriately use internal and external resources.
• Provide chronic disease care and management to complex patients, providing self-management support with a focus on empowering the patient/family to build capacity for self-care.
• Provide care management and coordination for adult and pediatric patients with complex illness, including transition of care calls in the primary care setting, under minimal supervision and in partnership with the primary care team.
• Manage a caseload of patients; provide targeted interventions to avoid hospitalization and emergency room visits.
• Integrate evidence based clinical guidelines, preventive guidelines, and protocols in the development of individualized care plans that are patient centered, promoting quality and efficiency in delivery of health care.
• Provide functional supervision to assistive personnel; collaborate with colleagues, other disciplines, and health/care community services to promote continuity of care.
• Other duties, with the scope of nurse and as assigned.