The posting
Job Description
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
Educational Requirements
- Graduate of an accredited Nurse Practitioner or Physician Assistant program
- Meets Texas requirements for Advanced Practice Nurses or Physician Assistant
Licenses and Certifications
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
Knowledge/Skills/Abilities
- 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
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
- 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
