under
indirect supervision and in
collaboration with physicians,
coordinate case management for members
residing in community long-term care
facilities; provide and ensure high
quality care to include assessment,
evaluation, development, facilitation,
and implementation of individualized
plans of care; collaborate with health
care team, patient, family, and
caregivers to assure safe, agreeable,
and appropriate patient plan of care.
Job
Description:
The
Clinical Nurse Specialist - Gerontology will perform
all or some of the following Job
description:
Provide
primary care and case management to
panel of members residing in
selected long-term care facilities
which include intake assessment,
evaluation, development of
individualized plan of care, annual
physical exam, timely
certifications, and
recertification's, routine follow-up
visits, and urgent visits in
collaboration with physician to
assess, diagnose, and implement
therapeutic plans of care including
prescribing medications, wound care,
and debridement within scope of
practice
Order and
monitor appropriate laboratory,
radiology, and other diagnostic
tests; educate patient and family
about health status, prognosis, and
treatment choices
Encourage and
document advanced directives
clarifications
Provide
consultation and direct care to
complicated geriatric inpatient,
outpatient, and home care patients
upon referral from physicians or
home health nursing staff
Participate as
member of Geriatric and Long Term
Care team in program development,
quality assurance, and quality
improvement processes
Document all
care provided to patients including
observations, treatments,
medications, and instructions
according to Regional and/or
facility standards; document all
communications and medical orders;
assure clinical record is accurate,
legible, and complete; complete
Hospital visit logs and required
encounter data in timely manner
Work
collaboratively with hospitals,
clinics, and community sites in
program development, and development
of policies, procedures, quality
assessment, and improvement
indicators for these programs
Identify needs
and coordinate in-service programs,
workshops, and seminars; actively
participate in educational program
planning, development, presentation,
and evaluation
Participate in
patient care conferences with other
health care team members to
coordinate, discuss, and evaluate
services provided to patient.
Knowledge of and skill in oral
communication, written
communication, teamwork, group
process facilitation, interpersonal
relations, customer service, and
problem solving
Ability to talk to co-workers,
customers, outside vendors, and on
the telephone
Ability to read, write, speak, and
understand English
Ability to train/give and receive
instructions
Mathematical ability, attention to
detail (e.g. organization,
prioritization, proofing),
concentration, and alertness.
