Adv Prac Provider | Chronic Disease Mgmt

Advanced Practice Provider - Chronic Disease Management Summary of Essential Functions

• Provides comprehensive acute and chronic patient care across inpatient setting

• Independently evaluates and manages patients within APP scope of practice

• Assesses patient health status and determines diagnostic and therapeutic needs

• Documents patient information accurately within the medical record

• Educates patients and families to support continuity of care

• Collaborates with physicians and interdisciplinary teams

• Acts as a liaison between providers, hospital, and community

• Work between the hours of 7a and 7p with weekend/holiday rotation

• Graduate of an accredited Nurse Practitioner or Physician Assistant program

• Meets Texas requirements for Advanced Practice Nurses or Physician Assistant

Current Texas Licensure Nurse Practitioner or Physician Assistant (PA)

• Eligible to obtain prescriptive authority (DEA/DPS as applicable)
• National certification as and Advanced Practice Nurse or Physician Assistant
• ACLS/PALS preferred

• Clinical experience preferred

• Experience in palliative care, hospice, internal medicine, hospital medicine, endocrinology or critical care preferred

• Strong critical thinking skills

• Completion of hospital orientation requirements

• Excellent verbal and written communication skills

• Commitment to patient-centered, compassionate care

• Ability to stand for extended periods and perform clinical tasks

• Ability to lift up to 50 pounds

• Ability to work in high-stress environments

• Exposure to blood borne pathogens

• Conduct comprehensive patient assessments, including medical history, physical examination, and review of diagnostic data to guide clinical decision-making
• Develop, implement, and adjust individualized, evidence-based care plans in collaboration with the interdisciplinary team and supervising physician as required
• Maintain compliance with applicable Texas Medical Board and Texas Board of Nursing supervision/collaborative agreements and regulatory requirements including periodic face-to-face meetings with supervision physician and documentation of chart review as required
• Provide education to patients, families and interdisciplinary team members on disease management, symptom control and goals of care.
• Document all patients encounters accurately and timely in the electronic medical record (e.g., EPIC), ensuring compliance with regulatory and organizational standards
• Collaborate with physicians, nursing staff, case management, social work, and other disciplines- and participate in interdisciplinary rounds as needed- to ensure coordinated, patient-centered care
• Perform palliative care consultations for patients with life-limiting illnesses
• Lead and support goals-of-care discussions, including advance care planning and code status clarification
• Assess and manage complex symptom burden
• Deliver compassionate, comfort-focused care for patients designated as comfort care, ensuring symptom relief, dignity, and alignment with established goals of care
• Participate in quality improvement initiatives focused on clinical outcomes, patient experiences and cost-effective care
• Provide emotional support to patients and families
• Coordinate care with hospice and community palliative resources
• Manage inpatient diabetes care, including glycemic control and insulin titration
• Utilize decision support clinical tools (e.g., Endo Tool) to support insulin management
• Collaborate with nursing on insulin and glucose monitoring practices
• Identify and address barriers to glycemic control
• Coordinate discharge planning and outpatient referrals
• Facilitate transitions of care, including appropriate referrals and communication with outpatient providers
• Participate in interdisciplinary rounds and discharge planning
• Identify high-risk patients and implement interventions
• Provide staff education and support when needed
• Participate in program development and workflow improvement
• Serve as a clinical resource and mentor
• Contribute to quality improvement initiatives and monitor key metrics
• Maintain licensure and certifications
• Adhere to scope of practice and agreements
• Uphold confidentiality and professional standards
• Performs all other tasks/responsibilities as necessary