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.

Performance Responsibilities and Standards:

• 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.

Requirements:

• 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 nursing care knowledge related to primary care/community health/chronic disease management
• Knowledge and awareness related to cultural competence, social determinants of health, concepts of health promotion, disease prevention, behavior change counselling, program planning, individual and group counselling
• Working knowledge of medical outpatient office processes, terminology, procedures and equipment required
• Ability to work independently and be self-directed
• Knowledge of electronic health records and proficiency in Microsoft office programs required
• Effective organizational, critical thinking, problem-solving and decision-making skills
• Excellent communication skills and ability to adapt communication styles to meet the needs of patients, health team members and community partners

Physical Requirements:

Mobility and Movement

• Ability to stand, walk, and remain on feet for extended periods while performing clinical duties.
• Capability to bend, stoop, kneel, crouch, and reach as needed to assist patients or access supplies.
• Frequent movement between clinic, patient homes, nursing homes, and other facilities.
• Ability to climb stairs and navigate varying home or facility layouts.

Driving and Transportation

• Regular operation of a personal or agency assigned vehicle for travel to patient homes or facilities.
• Ability to get in and out of a vehicle multiple times throughout the day.
• Capability to transport necessary medical supplies and equipment.

Manual Dexterity and Coordination

• Proficiency in using hands and fingers for tasks such as drawing blood, administering injections, and using medical instruments.
• Typing and data entry skills for documentation and electronic medical records (EMR) on computers or tablets.

Strength and Physical Stamina

• Ability to lift, carry, push, or pull up to 50 pounds, such as medical equipment or assisting patients with mobility.
• Capability to assist patients with transfers, positioning, or ambulation as necessary.
• Endurance for long workdays involving travel, physical activity, and patient care.

Vision and Hearing

• Adequate vision for reading medical instruments, patient records, and digital screens.
• Hearing ability sufficient to communicate effectively in person and over the phone or video calls, and to recognize alarms or patient needs.

Technology Use

• Frequent use of a phone, computer, and other electronic devices for communication, scheduling, and documentation.
• Ability to adapt to telehealth technology and remote patient monitoring tools.

Work Environment Adaptability

• Comfort working in varied settings, including office environments, patient homes, and nursing facilities, with exposure to differing noise levels, lighting, and temperature conditions.
• Ability to work in environments that may include pets, clutter, or other unique home conditions.

Postural Tolerance

• Capability to sit for extended periods while performing office work or driving between locations.
• Ability to switch between sitting, standing, and walking as needed for various tasks.

Bloodborne Pathogens Exposure

• Category I - Employee has tasks that routinely involve exposure or potential exposure to blood, body fluids or tissues)
• Protective measures should be readily available.

Compensation & Benefits:

Competitive Salary [This position is an S03 exempt position with a min-max rate of: $75,250- $87,138.92/annually] with:

• $15,000 sign-on bonus*
• Retention Bonuses
• Internal Mentoring Program
• 401K with generous Employer match
• On-Site Gym (free for all employees)
• Excellent work/life balance (no rotating shifts, only 2 required holidays per year on a rotating schedule)
• Medical, Dental, Vision plans
• Tuition Reimbursement (BSN after only 6 months of employment!)
• Partially funded HSA
• Employee Recognition Platform
• Paid Time Off, Holidays, Sick and Extended Sick Leave
• Short/Long term Disability
• Employee Assistance Program (EAP)
• Much More!

* Subject to specific terms and conditions*