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. 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* Eligible Site for the Nurse Corps Loan Repayment Program 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! ________________________________________________ About Nascentia Health Nascentia Health is leading the way in home care, post acute care and long‑term community health. A healthcare system without walls, Nascentia is an innovator in the concept of healthcare, truly focused on the patient as a whole. By serving people in their homes, Nascentia Health is able to provide true holistic care. We can address immediate needs, help support positive long term medical and lifestyle choices that provide for better outcomes, leverage cutting edge in‑home care technologies, and help avoid unnecessary visits to busy healthcare facilities. Our employees are our greatest asset. They work hard every day to make our system amazing and are dedicated to our mission of being the premier home and community‑based care system for the regions we serve. We want everyone to love what they do, be excited about coming to work, and take pride in being part of our team. Nascentia Health is an Equal Opportunity Employer (EOE) Employment is contingent upon negative results of a pre‑hire drug screen and background check * Subject to specific terms and conditions* #J-18808-Ljbffr