Registered Nurse - Care Coordinator, Internal Med-Pulmonology

Patient Population (Clinical Care)

• Communicates effectively with patients and families using age and population-appropriate approaches.
• Demonstrates knowledge of growth, development, and age-specific care considerations.
• Provides clear and comprehensive instructions regarding treatment plans and care.
• Involves patients, families, and caregivers in assessment, treatment planning, and ongoing care.
• Identifies physical limitations and implements appropriate interventions to ensure safety and optimal outcomes.
• Recognizes and appropriately responds to behavioral health concerns.
• Interprets population-specific data to guide patient care planning and interventions.
• Addresses psychological, cultural, religious, and social factors that may impact care delivery.
• Safely performs treatments, administers medications, and operates clinical equipment.
• Recognizes signs and symptoms of abuse or neglect and follows appropriate reporting procedures.

Patient Assessment & Interventions

• Serves as an expert clinician and role model in delivering high-quality patient care within the specialty area.
• Utilizes the nursing process to assess, plan, implement, and evaluate patient care.
• Performs comprehensive health assessments and reassesses patients throughout clinic visits as needed.
• Documents nursing histories, assessments, and referrals accurately and timely.
• Collects, analyzes, and monitors basic and advanced patient data to identify trends affecting health outcomes.
• Maintains patient comfort and safety throughout the ambulatory care experience and continually assesses environmental safety risks.
• Responds to emergent situations using evidence-based nursing standards, policies, procedures, and protocols.
• Provides accurate and effective handoff communication during transitions of care.
• Identifies and reports changes in patient condition, including abnormal diagnostic and laboratory findings.
• Performs point-of-care testing and interventions to support clinical outcomes and patient experience.
• Develops and implements individualized care plans in collaboration with interdisciplinary healthcare teams.
• Utilizes evidence-based clinical pathways to promote consistent, high-quality care.
• Demonstrates competency in medication administration, wound care, and other direct nursing interventions.
• Completes nurse visits and clinical documentation accurately and within established timeframes.
• Assists with minor procedures and diagnostic testing while ensuring patient comfort and safety.
• Monitors patient progress, communicates findings to the healthcare team, and adjusts care plans as necessary.
• Supports patient recruitment and participation in clinical research studies when appropriate.
• Collaborates with staff nurses on quality assurance and performance improvement initiatives.
• Establishes rapport with new patients by introducing self and explaining the nursing role.
• Prioritizes patient care needs effectively based on assessment findings and clinical judgment.
• Demonstrates critical thinking and accountability when evaluating and implementing provider orders.
• Maintains accurate, complete, and real-time nursing documentation in accordance with organizational policies and regulatory standards.
• Maintains a professional, positive, and collaborative demeanor in all interactions and remains composed during challenging or emergent situations.

Patient Education

• Assesses patient and family educational needs related to health promotion, disease management, diagnostic testing, treatment plans, and interdisciplinary care.
• Educates patients and families on medical conditions, medications, treatment plans, and self-care strategies.
• Evaluates understanding and provides reinforcement or additional education as needed.
• Incorporates current evidence-based literature and best practices into patient education.
• Serves as an expert resource for disease-specific and clinic-based patient education.
• Documents educational interventions, patient responses, and demonstrated understanding.

Facilitation of Care

• Coordinates referrals, follow-up appointments, and access to services to ensure seamless transitions across the continuum of care.
• Communicates test results, treatment recommendations, and follow-up plans effectively with patients and families.
• Addresses patient concerns while providing ongoing support, advocacy, and guidance.
• Anticipates evolving patient and family needs to reduce delays in care, improve access, minimize financial barriers, and enhance patient satisfaction.
• Participates in interdisciplinary care team meetings and treatment planning discussions.
• Collaborates with social workers, dietitians, case managers, and other healthcare professionals to address comprehensive patient needs.
• Serves as a liaison between departments and coordinates interdepartmental initiatives and projects.
• Participates in transition-of-care planning and execution.
• Documents collaborative care plans developed with the interdisciplinary healthcare team.
• Supports prior authorization processes for medications, treatments, and diagnostic services.

Leadership & Professional Development

• Participates in nursing, departmental, and organizational committees that influence patient care delivery and clinical practice.
• Assists in the development, revision, and implementation of nursing policies and procedures.
• Promotes and supports evidence-based practice initiatives.
• Collaborates in system-wide performance improvement and quality initiatives.
• Demonstrates leadership within the healthcare team while promoting accountability, responsibility, and excellence in patient care.
• Serves as a clinical resource and subject matter expert within the specialty area.
• Participates in staff orientation, competency validation, and educational programs as assigned.
• Precepts and mentors nursing students, clinical interns, and healthcare professionals, fostering professional development and learning opportunities.
• Maintains current knowledge of emerging research, clinical guidelines, and specialty nursing practices.
• Actively participates in and contributes to staff meetings and professional development activities.

Compliance & Safety

• Maintains confidentiality and protects patient information in accordance with legal and organizational requirements.
• Demonstrates understanding of regulatory, accreditation, and compliance standards impacting patient care delivery.
• Ensures adherence to departmental and organizational safety policies and procedures.
• Partners with nursing leadership and interdisciplinary teams to identify, implement, and share safety best practices.
• Maintains knowledge of legal and regulatory requirements, including HIPAA, EMTALA, accreditation standards, organizational policies, and reimbursement processes.
• Utilizes safety reporting systems effectively to identify, document, and escalate patient safety concerns as appropriate