Clinic Registered Nurse Coordinator - USFTGP Internal Medicine

The Clinic RN Coordinator collaborates with the health care team to develop theory-based patient care for patients undergoing complex care and surveillance. Reviews patient records, interviews patients, refers patients for initial visit and documents in EMR for incoming communications. Reviews medical record to anticipate clinical stability and have thorough understanding of the patient prior to follow-up with the patient and physician. Ensures patient is progressing through clinical milestones and adjusting treatment plan as needed. Collaborates with interdisciplinary team members to continuously identify more effective strategies to resolve barriers, reduce the severity of chronic disease, and coordinate transitions of care between Inpatient/Emergency Department/Ambulatory. Escalates barriers to care plan (clinical, social, and environmental) through appropriate channels to resolution. Responsible for patient, significant other, and nursing staff education regarding complex disease management. Provides effective clinical health coaching to assist patients with self-management of their chronic disease and lifestyle changes to mitigate health risk. Responsible for performing job duties in accordance with the mission, vision and values of Tampa General Hospital (TGH) and University of South Florida Tampa General Physicians (USFTGP).

Essential Functions

• Reviews patient medical history, physical conditions, medical diagnosis, available treatment options, financial resources and physician orders, comparing care plan to make necessary revisions.
• Patient intake, evaluation and referral; screens, monitors and documents patient progress, requesting images, records, and ordering any additional, required pre-operative labs or imaging to facilitate clinic visit.
• Completes frailty screening for patients and initiates risk assessment chart in preparation for patient to be seen in clinic.
• Determines appropriate course-of-treatment and develops and implements individualized care plans.
• Collaborates with MA and LPN teams to assist with ensuring pre-visit chart checks are complete and accurate.
• Coordinates surveillance, ensuring comprehensive patient list.
• Refers patient to appropriate ambulatory, hospital, and community resources.
• Provides accurate and consistent documentation of services including assessment, care plans, education and reassessment, and involvement with physicians.
• Collaborates with Social Work to manage the needs of patients who have high acuity psychosocial needs coupled with need for medical care to mitigate risk for hospital admission/readmission.
• Works in partnership with physicians to consider alternate levels of care if patient is not meeting clinical stability.
• Participates in department and organizational performance improvement activities.
• Participates in orientation and education of new team members and students.
• Utilizes AKTiVE and USFTGP behaviors, values, interactions with all patients and staff.
• Performs duties according to established procedures, protocols and professional standards.
• Associate's degree Nursing
• Florida Department of Health Nursing License
• Three (3) years nursing experience in an acute care or ambulatory setting.