Primary Care Registered Nurse

Position Description

The role of the RN in primary care is to provide nursing care to a diverse group of patients and families in a community-based setting using the knowledge, skills and abilities of the nursing profession. The RN is a central team member in the delivery of quality and cost-effective primary care services. The Primary Care RN is responsible for managing a group of patients who require intensive oversight and helps individuals, families and groups reach their maximum level of wellness through a variety of techniques including health coaching.

The Primary Care RN works in an ever-changing environment and, as such, invests considerable time in maintaining their professional expertise and maintaining a strong evidence-based approach. The Primary Care RN acquires and maintains a comprehensive understanding of health and social services as well as referral processes, including diagnostic services, specialists, hospital care, rehabilitation and support programs, educational programs, and community-based health agencies.

They are also involved in many initiatives aimed at improving healthcare practice, identifying risk and safety issues and facilitating resolution.

• Administration and management of clinical support staff operations; maintain coordination of services and communication among program components
• Initiates and/or contributes to the development of a health plan in collaboration with the patient and other members of the interdisciplinary team.
• Assists and supports patients with implementation of the health plan including interventions and diagnostic testing. This may involve setting up supports such as medication delivery/adherence programs for medications, assisting with transportation, arranging in-home care, etc.
• Determines the need for and initiates consultations with other services and health-care providers in a timely and supportive manner.
• Monitors, evaluates and adjusts the health plan based on effectiveness of interventions and/or changes in condition or environment, in collaboration with the patient and team members.
• Provides telephone care, follow-up and consultation. Documents this care in patient record or according to agency policy.
• Informs and educates patients regarding the meaning and implications of test results and interventions.
• Counsels patients on drug therapies, side-effects and interactions.
• Counsels and guides patients on symptom management, health maintenance and rehabilitation strategies, as well as risk factors and lifestyle changes.
• Coordinates services and care with the patient to ensure continuity and follow-up.
• Initiates or participates in patient care case conferences to ensure coordinated, comprehensive and holistic services.
• Provides care in collaboration with providers for patients in long-term care or assisted living, including home visits as required.
• Prepares prescriptions for signing or facilitates the ordering of medications according to practice policy.
• Completes necessary documents to access medications or treatments that are exceptions to formulary.
• Communicates with secondary and tertiary providers to ensure the continuity of care.
• Networks with community agencies and groups.
• Completes referrals or consults, lab requisitions, and diagnostic requisitions. Ensuring follow-up as appropriate.
• Assist with Pharmaceutical Patient Assistance Applications, sample meds, vaccines, including the VFC program and ensure that documentation of medication-related activities are accurately documented
• Order and maintain storage of necessary medications and medical supplies in accordance with agency policies and procedures including the monitoring of proper refrigeration
• Participate in the QAPI program including PDSA cycles for Process Improvement
• Manages and supervises nursing care provided to patients and delegates tasks appropriate to scope of practice.
• Ensure that all incidents are documented and reported
• Participate in the recruitment, hiring, and training of nursing staff
• Work with clinic staff and providers to ensure seamless and efficient clinic flow for patients
• Ensures progress and development is made toward departmental strategic plan goals
• Perform all other duties as assigned.

• Associates Degree in Nursing with a Bachelors Degree in nursing preferred
• NYS License as Registered Professional Nurse, current CPR certification.
• Valid driver’s license and access to a vehicle
• At least two (2) years of primary care (or related) experience with…