What are the responsibilities and job description for the Nurse Lead position at The Annex?
Position Title: Lead Nurse
Reports To: Program Director
Supervises: N/A
Position Classification: Non-Exempt
Summary
The Lead Nurse provides direct client care and medical support under the supervision of the Medical Director. This role oversees the self-administration of medication processes and serves as a mentor and point of contact for other healthcare staff. The Lead Nurse ensures medical coordination, accurate documentation, and compliance with all clinical, licensing, and regulatory standards.
Supervisory Responsibilities
This position does not include supervisory responsibilities but serves as a mentor and informal lead to other nursing and technician staff.
Essential Responsibilities
Support and Assist the Medical Director
- Coordinate medical scheduling and serve as liaison between the Medical Director and the broader care team
- Assist in carrying out physician’s orders
- Communicate with pharmacies, outside providers, and Clinical Team
- Support administrative tasks as requested
Client Care
- Complete nursing assessments at intake and discharge per protocol
- Monitor and document changes in client symptoms and behavior
- Take and record vital signs (height, weight, temperature, blood pressure, pulse, respiration)
- Meet with clients to review medications and answer questions
- Observe and report withdrawal symptoms in accordance with protocol
Medication and Self-Administration Oversight
- Educate clients on prescribed medications and support medication self-administration
- Accurately document medication administration in the MAR system
- Monitor medication adherence and destruction protocols
- Observe and report adverse medication reactions or events
Collaboration and Communication
- Provide training and support to technicians on medical policies and procedures
- Maintain accurate documentation in the electronic medical record (EMR)
- Ensure HIPAA compliance and adherence to state, federal, and accreditation standards
- Participate in team meetings and ongoing program development
Other Duties
- Perform additional tasks as assigned by leadership
- Participate in staff training, supervision, and continuing education as needed
Required Knowledge, Skills, and Abilities
- Strong understanding of behavioral health and psychological disorders within LVN/RN scope of practice
- Ability to de-escalate agitated clients professionally and calmly
- Proficient in documentation and medical record keeping
- Excellent interpersonal, verbal, and written communication skills
- Ability to work collaboratively within a multidisciplinary team
- Strong organizational skills and attention to detail
- Demonstrated understanding and compliance with agency policies
Education and Experience
- Current Licensed Vocational Nurse (LVN) or Registered Nurse (RN) license in the State of Texas
- Minimum of 1 year of nursing experience in a behavioral health or related setting
- High school diploma or GED required
- Must be at least 18 years of age
- Experience working with individuals with mental health conditions preferred
- CPR/First Aid certification required
- Current TB test and required health screenings
- Must pass criminal background check
