Job Description

Advanced Practice Provider - Chronic Disease Management

Summary of Essential Functions

• Provides comprehensive acute and chronic patient care across inpatient setting
• 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

Educational Requirements

• Current Texas Nurse Practitioner License or Physician Assistant (PA)
• Effective verbal and written communication skills

Licenses and Certifications

• Meets Texas Board requirements for Advanced Practice Nurses or Physician Assistant
• Current prescriptive authority (DEA/DPS as applicable)
• National certification as an Advanced Practice Nurse or Physician Assistant
• ACLS/PALS preferred

Knowledge/Skills/Abilities

• Clinical experience preferred
• Strong critical thinking skills
• Completion of hospital orientation requirements

Physical Requirements

• 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 bloodborne pathogens

Duties and Responsibilities
• 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
• Provide patient and family education to improve understanding of disease processes, treatment plans, and expected outcomes
• Document all patient 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 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
• 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 clinical tools (e.g., EndoTool) to support insulin management
• Collaborate with nursing on insulin and glucose monitoring practices
• Address barriers to glycemic control
• Coordinate discharge planning and outpatient referrals
• Facilitate transitions of care and communicate 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