Description

Gather clinical data of assigned patients for providers. Document clinical data to include, but not limited to, HPI, medication reconciliation, medical history, medication allergies, family history, social history, vital signs, preventive medicine and appropriate developmental screenings.   Assist Provider(s) with examinations, reviewing lab results, in-house procedures, vision and hearing screenings, facilitating referrals and prior authorizations with appropriate documentation. 

Requirements

Duties and Responsibilities

1.        Gather clinical data of assigned patients for providers. Document clinical data to include, but not limited to, HPI, medication reconciliation, medical history, medication allergies, family history, social history, vital signs, preventive medicine and appropriate developmental screenings.

2.        Administers medications, immunizations, and therapeutic injections as ordered by the provider while following clinical policy.

3.        Assist Provider(s) with examinations, reviewing lab results, in-house procedures, vision and hearing screenings, facilitating referrals and prior authorizations with appropriate documentation.

4.        Gather clinical data from guardian for patient sick calls in accordance with clinical policies under the direction of the medical provider.

5.        Review daily charts with providers to address patient preventive healthcare maintenance, immunization schedule, recent hospitalizations, developmental screenings, potential risk factors and CDSS alerts.

6.        Report any significant patient conditions or reactions to medications or procedures immediately to the provider or Clinic Nurse Manager.

7.        Provide patient and parent education on medications, immunizations, medical procedures, and referrals.

8.        Performs phlebotomy laboratory processing and CLIA waived in house testing as needed.

9.        Assist in the evaluation of patient encounters in regard to coding in the EMR for procedures to optimize billing.

10.     Notify patient of lab results, procedure results and referral appointments.

11.     Explain ordered procedures or treatments to patients and guardians.

12.     Assist SW staff with required refills for patients’ assistance programs.

13.     Input patient data into EClinicalWorks.

14.     Sanitize exam rooms and restock supplies used in exam rooms as needed.

15.     Float between other departments as needed.

16.     Set up AV equipment for Telemedicine and assist Provider(s) in seeing patients via Telemedicine.

17.     Participate in team meetings.

18.     Participate in Quality Improvement projects as directed by the Clinic Nurse Manager or Director of Nursing.

19.     Maintain active CPR certification.

20.     Maintain certification by successful completion of medically related CEU’s.

21.     Other responsibilities assigned by Director of Nursing or Nurse Manager

Knowledge, Skills, and Abilities

• Knowledge of HIPAA laws.
• Knowledge of HIV transmission, prevention, and disease process

·         Ability to work independently with minimum supervision.

·         Basic computer literacy skills including but not limited to EMR, MS, Excel and CAREWare.

·         Ability to work with patients, significant others, and staff from diverse populations.

·         Ability to effectively communicate with staff and patients.

Summary

          Gather clinical data of assigned patients for providers. Document clinical data to include, but not limited to, HPI, medication reconciliation, medical history, medication allergies, family history, social history, vital signs, preventive medicine and appropriate developmental screenings.   Assist Provider(s) with examinations, reviewing lab results, in-house procedures, vision and hearing screenings, facilitating referrals and prior authorizations with appropriate documentation.