Job Description

Advanced Practice Provider - Chronic Disease Management

of Essential Functions

• Provides comprehensive acute and chronic patient care across inpatient setting

• 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

Educational Requirements

• Current Texas Nurse Practitioner License or Physician Assistant (PA)

• Effective verbal and written communication skills

Licenses and Certifications

• Meets Texas Board requirements for Advanced Practice Nurses or Physician Assistant

• Current prescriptive authority (DEA/DPS as applicable)

• National certification as an Advanced Practice Nurse or Physician Assistant

• ACLS/PALS preferred

Knowledge/Skills/Abilities

• Clinical experience preferred

• Strong critical thinking skills

• Completion of hospital orientation requirements

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

• Provide patient and family education to improve understanding of disease processes, treatment plans, and expected outcomes

• Document all patient 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 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

• 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 clinical tools (e.g., EndoTool) to support insulin management

• Collaborate with nursing on insulin and glucose monitoring practices

• Address barriers to glycemic control

• Coordinate discharge planning and outpatient referrals

• Facilitate transitions of care and communicate 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