Clinical Nurse Specialist

Job Description

Purpose: The Nurse Practitioner Advanced Illness Management (AIM) facilitates advanced illness management and palliative care for patients, ensuring a comprehensive, individualized treatment plan, while demonstrating excellent clinical skills and ethical, relevant judgment.

Main Responsibilities:

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• Provide diagnosis, treatment, consultation, and follow-up under the direction of the Palliative Medical Director or Primary Care physician;
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• Work in collaboration with the Professional Services Corporation (PSC) Physician or supervising physician, Primary Care Physician, and other palliative team members to deliver advanced illness management and palliative care by providing diagnosis, treatment and follow-up for patients referred to the company;
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• Take responsibility for advanced illness management from the initial assessment through discharge, assessing disease-specific changes, decline or change in function, nutrition and/or cognition, inadequately controlled pain or other distressing symptoms, falls, infections or similar events, the impact of the disease burden on the patient's condition, caregiver and/or family's quality of life;
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• Establish the plan of care, individualized for each patient, in consultation with the patient, family and other members of the Advanced Illness team, to include the PCP;
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• Facilitate obtaining care for patient when a need is identified in accordance with the Plan of Care;
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• Participates in evening/weekend call as required, conducting on-call services in a clinically competent and responsive manner;
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• Order treatments and durable medical equipment as indicated;
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• Communicate clinical findings to the PSC Physician as needed, but no less than bi-weekly. Re-assess effectiveness of care plan on a regular basis and modify as needed;
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• Maintain effective working relationships with supportive care team (e.g., Social Worker and RN Care Manager), as applicable, and involve team (internally and externally) when patient's care plan warrants team participation to achieve desired outcome;
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• Communicate and document clinical findings, treatment plan, and care provided in the patient's medical record in a manner consistent with acceptable standards in order to support sound medical practice and reimbursement for services provided;
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• Knowledgeable of Palliative Medicine Quality Measures collection, documentation and reporting.
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