Advanced Practice Provider - Chronic Disease Management Summary of Essential Functions • Provides comprehensive acute and chronic patient care across inpatient setting • Independently evaluates and manages patients within APP scope of practice • Assesses patient health status and determines diagnostic and therapeutic needs • Documents patient information accurately within the medical record • Educates patients and families to support continuity of care • Collaborates with physicians and interdisciplinary teams • Acts as a liaison between providers, hospital, and community • Work between the hours of 7a and 7p with weekend/holiday rotation Educational Requirements • Graduate of an accredited Nurse Practitioner or Physician Assistant program • Meets Texas requirements for Advanced Practice Nurses or Physician Assistant Licenses and Certifications Current Texas Licensure Nurse Practitioner or Physician Assistant (PA) • Eligible to obtain prescriptive authority (DEA/DPS as applicable) • National certification as and Advanced Practice Nurse or Physician Assistant • ACLS/PALS preferred Knowledge/Skills/Abilities • Clinical experience preferred • Experience in palliative care, hospice, internal medicine, hospital medicine, endocrinology or critical care preferred • Strong critical thinking skills • Completion of hospital orientation requirements • Excellent verbal and written communication skills • Commitment to patient-centered, compassionate care Physical Requirements • Ability to stand for extended periods and perform clinical tasks • Ability to lift up to 50 pounds • Ability to work in high-stress environments • Exposure to bloodborne pathogens • Duties and Responsibilities • Conduct comprehensive patient assessments, including medical history, physical examination, and review of diagnostic data to guide clinical decision-making • Develop, implement, and adjust individualized, evidence-based care plans in collaboration with the interdisciplinary team and supervising physician as required • Maintain compliance with applicable Texas Medical Board and Texas Board of Nursing supervision/collaborative agreements and regulatory requirements including periodic face-to-face meetings with supervision physician and documentation of chart review as required • Provide education to patients, families and interdisciplinary team members on disease management, symptom control and goals of care. • Document all patients encounters accurately and timely in the electronic medical record (e.g., EPIC), ensuring compliance with regulatory and organizational standards • Collaborate with physicians, nursing staff, case management, social work, and other disciplines- and participate in interdisciplinary rounds as needed- to ensure coordinated, patient-centered care • Perform palliative care consultations for patients with life-limiting illnesses • Lead and support goals-of-care discussions, including advance care planning and code status clarification • Assess and manage complex symptom burden • Deliver compassionate, comfort-focused care for patients designated as comfort care, ensuring symptom relief, dignity, and alignment with established goals of care • Participate in quality improvement initiatives focused on clinical outcomes, patient experiences and cost-effective care • Provide emotional support to patients and families • Coordinate care with hospice and community palliative resources • Manage inpatient diabetes care, including glycemic control and insulin titration • Utilize decision support clinical tools (e.g., Endo Tool) to support insulin management • Collaborate with nursing on insulin and glucose monitoring practices • Identify and address barriers to glycemic control • Coordinate discharge planning and outpatient referrals • Facilitate transitions of care, including appropriate referrals and communication with outpatient providers • Participate in interdisciplinary rounds and discharge planning • Identify high-risk patients and implement interventions • Provide staff education and support when needed • Participate in program development and workflow improvement • Serve as a clinical resource and mentor • Contribute to quality improvement initiatives and monitor key metrics • Maintain licensure and certifications • Adhere to scope of practice and agreements • Uphold confidentiality and professional standards • Performs all other tasks/responsibilities as necessary