Overview Responsible for coordinating the care and clinical services within a medical home model for patients with complex medical conditions. Works with and supports physicians and ARNPs in all aspects of clinical practice management. Utilizes nursing skills to provide excellent care to patients and families with complex medical conditions. Applies knowledge, growth and development, pathophysiology and family dynamics in delivery of care to respond to patient and family questions and triage patient needs in support of and in collaboration with physicians and nurse practitioners. Helps to coordinate primary and specialty care, responding to and triaging patient/family calls to determine whether a patient needs immediate care and/or other dispositions. This position officially reports to the Community and Division Manager but will also be accountable to the Multispecialty Clinic Office Manager and the Ambulatory Administrator. Responsibilities Handles all incoming calls and responsible for the processing of all In-basket requests in electronic medical record (EPIC) for clinics. Attends pertinent educational activities and reviews current literature relevant to clinical area of expertise. Participates in relevant nursing and specialty organizations. Ensure vaccines are stocked and in compliance. Schedules urgent pre-operative, flu, and Synagis appointments. Assesses individual physical, psychosocial and developmental needs of patients and family, and contributes to development of comprehensive plan of care. Identifies specific education needs for patients/families; delivers and evaluates the effectiveness of the teaching plan. Ensure vaccines are stocked and in compliance. Accurately and efficiently documents effectiveness of care, findings, plans, and interventions in the medical record. Responsible for documenting contacts, chart notes and other required data in medical record and the pertinent information systems used by the Multispecialty clinics. Schedules urgent pre-operative, flu, and Synagis appointments. Collaborates with family and healthcare team to arrange for identified home care needs. Acts as hospital liaison for agencies and individuals involved with care. Reviews all home nursing agency and PPEC orders for accuracy before submitting to the physician for signature. Evaluates the effectiveness of care and documents subsequent changes to plan or follow up in patient medical record/EMR. Reviews all specialists notes and ensures that the patient's medical record is up to date with current information. Recognizes the need for referral to other sub specialists, other agencies for providers and facilitates the process. Coordinates with outside pharmacies, patient hospital discharge planning and specialists as necessary for patient care. Additional duties as assigned may vary. Qualifications Experience Requirements: 2 years Clinical experience preferred Experience in administration of vaccines, nebulizer treatments, catheterization for urine and other interventions preferred Education: Associates degree required