Functions independently as a primary care practitioner as part of a patient care team. Independently assesses acute and non-acute clinical problems. Performs and documents physical assessments and patient histories, analyzes trends in patient conditions, and develops, documents and implements a patient management plan. Plans patient care based on in-depth knowledge of the specific patient population and/or protocol. Patient management includes: writing admission, transfer and discharge orders; ordering and interpreting appropriate laboratory and diagnostic studies; ordering of appropriate medication and treatments; referring patients for consultation when indicated. Participates in patient care rounds and conferences. Collaborates with members of the multidisciplinary team. Recognizes situations which require immediate attention and initiates life-saving procedures when necessary. Uses advanced communication skills to problem solve complex situations. Collaborates with other multidisciplinary team members to analyze and evaluate current systems of health care delivery. Participates in outside activities that enhance personal and professional growth and development. Initiates arrangements and writes orders for discharges and completes appropriate paperwork. Works collaboratively with physicians, nurses, PT, social workers, family and key caregivers to transition the patient to a lower level of care. Advocacy & Education-ensuring the patient has an advocate for needed services and any needed education. Introduces self to patient/family and explain primary care provider role. Facilitates patient/family conferences to review treatment goals, optimize resource utilization, provide family education and identify needs. Utilization/Financial Management-managing resource utilization and reimbursement for services. Facilitates discharge to appropriate level of care and uses preferred providers when additional services are required.