Position Overview: The Registered Nurse or RN provides professional nursing care to patients/significant others via direct and/or telephone contact, following established standards and practices. S/he coordinates with other members of the care team to ensure seamless care delivery, maximal coordination of efforts, and active patient participation in planning and care. Assists physician or other provider with clinical procedures, performs telephone triage as needed, and participates in patient teaching.

Provides Direction To: Licensed Practical Nurses, clerical assistants, medical assistants, and other non-licensed personnel.

Typical Physical Demands: Requires full range of body motion including moving and lifting patients, manual and finger dexterity and eye-hand coordination. Requires sitting and/or standing for extended periods of time. Occasionally exerts up to 100 pounds of force, such as assisting patients in arising from the exam table, pushing patients in wheelchairs, or assisting patients into/out of wheelchairs. Requires corrected vision and hearing to normal range. May require occasional lifting and carrying office supplies.

Typical Working Conditions: May require frequent exposure to communicable diseases and body fluids, toxic substances, medicinal preparations, and other substances and conditions common to a medical office environment. Requires working in close proximity to other personnel. Requires use of computer keyboard throughout the work day. May require use of autoclave for instrument sterilization. Requires working under stressful conditions and/or working irregular hours. 

MINIMUM QUALIFICATIONS: Graduate of an accredited school of nursing. Registered nurse licensed to practice in New York State (NYS) with current NYS registration and in good standing. Record of prior stable employment and/or favorable references.

PREFERRED QUALIFICATIONS: Minimum of one year experience as a registered nurse or two years as a licensed practical nurse in a pertinent practice area. Bachelor of Science in Nursing (B.S.N.). Current BLS certification. At least two years of recent pertinent professional nursing experience in a hospital, medical office, or other clinical setting.
NOTE: This document is intended to describe the general nature and level of work performed. It is not intended to serve as an exhaustive list of all duties, skills, and responsibilities required of personnel so classified. (6/2016) 

I. PERFORMANCE EXPECTATIONS

A. Clinical Knowledge and Skills

1. Demonstrates clinical competence in the direct care of patients/significant others in established area of practice, considering developmental differences among patients;
2. Demonstrates basic knowledge of common disease processes and treatments, including pertinent diagnostic/laboratory testing and medical/nursing interventions; familiar with preventative health measures related to population served
3. Demonstrates a proactive approach to patient care, focusing on addressing each patient’s individual and family needs at the time of service; communicates identified needs in a timely manner. 
4. Utilizes evidence-based approaches with patients/families/caregivers to support self-management, self-efficacy, and health-promoting behavior change.
5. Collaborates with patients/significant others and other members of the healthcare team to establish goals and priorities to meet patients’ immediate and future needs; Actively participates in the care team to ensure that patient needs and preferences are incorporated into the comprehensive plan of care
6. Using population-specific knowledge and clinical expertise, contributes to the continual assessment and effective management of the health needs of assigned patient populations
7. Performs telephone triage with particular emphasis on assessment, problem/priority identification, and decision-making;
8. Demonstrates knowledge, skills, and technical ability in medication/treatment administration; administers prescribed medications correctly, with knowledge of proper dosage, route, site, and possible side effects;
9. Provides accurate, up-to-date clinical information to patients consistent with professional nursing scope of practice and accepted CareMount Medical practice standards, policies, and protocols;
10. Uses the nursing process for problem-solving/decision-making;
11. Performs authorized technical procedures competently (e.g., EKG, phlebotomy, starting/ monitoring IVs, selected laboratory tests, etc.) as may be required in clinical practice area;
12. Demonstrates clinical competence when assisting MD or other provider with procedures;
13. Seeks validation/guidance from physician or other provider and nurse colleagues when necessary;
14. Functions effectively with other healthcare providers during emergency situations;
15. Understands and practices universal precautions correctly and consistently and complies with all applicable OSHA guidelines;
16. Ensures that all clinical equipment is maintained in clean, working order.

B. Communication

1. Maintains open lines of communication with physicians and other CareMount Medical personnel, within and between departments--even during periods of heightened stress;
2. Maintains open lines of communication with non-CareMount Medical physicians, pharmacies, and other community agencies and services;
3. Notifies patients/significant others and/or reception staff promptly of unanticipated MD/other provider delays or scheduling changes;
4. Demonstrates effective communication strategies reflective of the needs of all patients, including those from vulnerable populations 
5. Provides reassurance to patients who are upset and/or in need of assistance or additional information;
6. Directs and coordinates the work of LPNs, medical assistants, and other assistive personnel to meet identified patient care needs;
7. Maintains confidentiality of all information obtained from patient records and conversations with patients/significant others, physicians, and other CareMount Medical personnel
8. Answers telephone promptly (within three rings) and courteously and identifies self by name and department (and physician’s office by physician’s name, if appropriate);
9. Uses discretion and sensitivity during all phone conversations;
10. Uses a non-judgmental approach when talking with patients and coworkers;
11. Effectively and efficiently triages patient phone calls and schedules same-day (work-in) appointments as per departmental or individual physician guidelines;
12. Transfers telephone calls only when necessary and as per CareMount Medical policy;
13. Assists patients with referrals and pre-certifications as needed for managed care insurance plans with which CareMount Medical participates; communicates potential for additional care coordination with outside organizations and/or providers when identified 
14. Offers clinical advice to CareMount Medical patients according to departmental protocols, individual physician’s or other provider’s instructions, and/or accepted nursing practice;
15. Uses available electronic mail/computer systems to communicate inter- and intra- departmentally as per departmental and/or CareMount Medical protocol(s).

C. Teaching/Education of Patients/Significant Others

1. Uses clinical knowledge and skills to teach patients/significant others effectively (e.g., via written information, face-to-face communication, phone communication); 
2. Integrates patient and family education, including health promotion/wellness, into the 
delivery of care;
3. Continuously evaluates the results of patient education and modifies the teaching plan based on patient outcomes;
4. Suggests and/or facilitates referrals (e.g., to Department of Social Services, dietitian, hospice) as applicable;
5. Designs and implements educational activities that are culturally appropriate (and consistent with individual physicians’ practice) and are tailored to the patient’s/significant other’s ability to comprehend and participate;
6. Participates, as requested, in the development of patient-teaching tools/programs for 
assigned department.

D. Organizational Skills

1. Work area reflects neat and organized work habits;
2. Addresses all patient requests/concerns before end of shift (or notifies patient/significant other of additional time needed to complete request);
3. Sets priorities effectively to ensure timely completion of assigned work;
4. Requests assistance as appropriate in order to complete assigned work and offers to assist others when work load permits;
5. Prepares and leaves complete, concise messages/instructions for others as needed
6. Notifies patients of amount of time needed to address or answer their requests or questions; completes such requests as promptly as possible and/or notifies patient/significant others of anticipated (or unanticipated) delays;
7. Uses time, supplies, and human resources effectively and efficiently.

E. Documentation

1. Takes complete messages for all telephone calls, including but not limited to: correctly spelled full name and current telephone number(s) of caller, date, time, and reason for the call; signs full surname on all messages;
2. Documents in EHR all pertinent clinical observations, medications/ 
immunizations/treatments given, allergies, etc.;
3. Maintains legible log or documentation of all telephone calls received, including but not limited to: date and approximate time of call, full name, date of birth (if applicable), and telephone number of caller, as well as reason for call;
4. Documents pertinent telephone calls and significant nurse-patient interactions in patients’ EHR, including but not limited to: nursing advise or information provided to patients/guardians/significant others (on behalf of patient), medical advice or information provided to patients as directed by physician or other provider, communication with pharmacies, managed care companies, etc.; 
5. Records the full surname of physician or other providers in EHR when documenting information or advice as directed by that physician or other provider;
6. Signs all entries in medical record according to CareMount Medical policy.

F. Leadership

1. Demonstrates effective problem-solving skills, particularly when urgent/emergent or 
unexpected clinical or administrative events arise in order to maintain both the smooth 
functioning of the department and patient/personnel safety;
2. Serves as a catalyst for improving standards of nursing practice;
3. Demonstrates leadership skills through the ability to set and attain goals;
4. Serves as an effective role model for professional conduct and professional practice (e.g., maintaining composure during times of increased stress);
5. Provides direction and support, and delegates tasks to professional and non-professional staff;
6. Serves as an effective preceptor to new staff as needed;
7. Effectively performs the duties of charge nurses as needed;
8. Actively participates in departmental staff meetings.

G. Professionalism

1. Demonstrates self-direction, accountability, sound judgment, and ethical behavior in all activities;
2. Demonstrates patient advocacy;
3. Maintains a commitment to the spirit of inquiry as evidenced by a clinical knowledge base that remains current and reflects understanding of relevant clinical research findings;
4. Participates in professional conferences, workshops, continuing education programs, and/or pertinent professional organizations (e.g., American Association of Office Nurses, American Nurses Association/New York State Nurses Association, Sigma Theta Tau, American Academy of Ambulatory Care Nursing, National Association of Pediatric Nurse Associates and Practitioners [NAPNAP], etc.);
5. Reads current, clinically applicable professional journals.
6. Attends mandatory conferences/inservices in order to maintain (active) NYS registration, in good standing with the NY State Education Department.

H. Other Specific Responsibilities/Duties 

II. GENERAL RESPONSIBILITIES OF ALL EMPLOYEES

A. Arrives to work on time or notifies Patient Care Manager or designee as soon as employee becomes aware that s/he will be absent or tardy, and/or as per individual department protocol.
B. Maintains an acceptable attendance record as per CareMount Medical policies and procedures.
C. Notifies Patient Care Manager or designee whenever leaving CareMount Medical premises during scheduled work hours.
D. Attends all mandatory CareMount Medical programs and in-services.
E. Dresses according to CareMount Medical dress code.
F. Assumes responsibility for reading, understanding, and complying with information contained in the current CareMount Medical Employee Handbook, CareMount Medical Clinical and/or Administrative Policy & Procedure Manuals, as applicable.
G. Maintains patient confidentiality under all circumstances, and follows all CareMount Medical policies regarding confidentiality.
H. Assists Patient Care Manager and/or designee, and/or other administrative personnel when possible by taking on alternate assignments or other responsibilities, working additional hours, or altering regularly scheduled hours, when necessary, for the efficient operation of CareMount Medical.

Qualifications

Skills

Preferred

Nursing

Physical Assessment

Education

Preferred

• Associates or better in Nursing.
• Bachelors or better in Nursing.
• Licenses & Certifications

Required

• Basic Life Support
• Infection Control Cert
• Registered Nurse

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