Registered Nurse, Clinical Lead - Waxhaw

Registered Nurse, Clinical Lead - Waxhaw Primary Care

General Job Summary: Responsible for providing professional nursing care for patients including assessment, treatment, care planning, and medical care evaluation by following established standards and practices. Assists physicians and staff in coordinating patient care. Functions as primary liaison between patients, staff and physicians. 

• Obtains patient consent for care and ensures patient confidentiality.
• Obtains and documents health history, information on chief complaint, vital signs, and health risk factors and assesses disease condition.
• Provides patient care based on practice guidelines, standards of care, and federal/state laws and regulations.
• Executes prescribed treatments and medical interventions, administers prescribed medications, and monitors and documents treatment progress and patient response. 
• Delegates as allowed under the Nurse Practice Act. Refers to/consults with physicians, other health providers, and community resources to prevent/resolve problems or concerns.
• Educates patients and families about health status, health maintenance, and management of acute and chronic conditions.
• Documents patient assessment and intervention data using established medical record forms/automated systems and documentation practices.
• Tracks quality assurance data and monitors for acute and chronic care management.
• Maintains/reviews patient records, charts and other pertinent information.
• Order entry with EHR
• Starting IV’s and administering IV fluids
• Complete forms and prior authorizations for medications.
• Be the point person for emergencies/triage walk ins (Chest pain, hypoglycemia, syncope)
• Participate in code blue as necessary
• Medication refills
• Patient education regarding insulin, MDI use
• Assist MAs as needed with any and all their responsibilities as need arises in order to maintain adequate patient flow or as needed by the provider.
• Other duties as assigned.

• Serves as the first escalation point for telephone calls and message received by Medical Assistant. Talks directly to the patient on the telephone.
• Performs short evaluation of the patient situation to estimate severity of illness and/or injury including learning about chief complaint and, as possible, obtaining vital sign and mental status information.
• Determines urgency of seeing the patient based on brief assessment and on familiarity with a patient’s condition and history. 
• Directs patient to the appropriate site of care:
  • During office hours, to their provider or other available practice providers
  • Urgent care centers
• Sends patients with high-risk chief complaints such as chest pain, abdominal pain, or severe headaches to ER immediately or arranges for ambulance etc.
• Provides appropriate home health advice to patients who do not need to go directly to the ER.
• Ensures accurate notes of all consultations and treatments are recorded in the patients’ record via the clinical computer system.
• Arranges appointments for patients who do not need to go to ER but need to see a physician. Consults with physician as needed.
• Responds to routine information requests from patients
• Performs other duties as assigned.

• RN degree. Completion of nursing training from an accredited school of nursing. BSN preferred.
• Current state registered nurse license.
• Current CPR certificate.
• Maintain American Heart Association or American Red Cross BLS certification. Maintain Advanced Cardiovascular Life Support certification (ACLS) if role requires. Note: May be required for Cardiology or Pulmonary roles.
• Completion of Hepatitis B Vaccine and Flu Vaccine Form will be required. Candidate may decline vaccination through declination form or may provide record of vaccination from previous employer.
• Completion of TB test will be required.

• Minimum of one-year professional nursing experience, clinic experience preferred.
• E.H.R. utilization
• Serving customers in person and on the phone

• Work consistently requires walking, standing, sitting, lifting, reaching, stooping, bending, pushing, and pulling.
• Must be able to lift and support weight of 35 pounds.
• Ability to concentrate on details.
• Use of computer for long periods of time.