Title: Health Home Project Nurse
Location: North Chester/Shafter
Job Summary: The Health Home Project (HHP) Nurse has the responsibility to coordinate care to (age-specific) patients by developing, monitoring, and evaluating interdisciplinary care.
- Participates in Health Home Project team meetings and quality improvement initiatives.
- Facilitates health and disease patient education, including leading group office visits.
- Supports patient self-management of disease and behavior modification interventions.
- Coordinates continuity of patient care with external health organizations and facilities, including the process hospital admission and discharge and referrals from primary care provider to specialty care provider.
- Coordinates continuity of patient care with patients and families following hospital admission, discharge, and ER visits.
- Manages high-risk patient care; including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting, including a registry.
- Conducts comprehensive, preventive screenings for patients and/or assists all support staff in daily patient interactions as needed.
- Promotes clear communication amongst care team and treating clinicians by ensuring awareness regarding patient care plans.
- Facilitates patient medication management based upon standing orders and protocols.
- Participates on a team for data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to the Health Home Project.
- Evaluates clinical care, utilization of resources, and development of new clinical tools, forms, and procedures.
- Oversight of Medical Assistants in the Health Home Project.
- Develop training material and train staff as required.
- Assist with Medical Assistant competency upon hire and annually thereafter.
- Assists all patients through the healthcare system by acting as a patient advocate and navigator.
- Participates in community functions as appropriate.
- Assume other responsibilities as required.
- HIPAA compliance – responsible for maintaining abreast of and in compliance with all H.I.P.A.A. regulations and requirements. Treats all member information confidential.
- Compliance – Ensure compliance with all local, state and federal regulations.
- QA/QI – Participate in QA/QI activities and contribute towards the overall performance improvement of the organization.
- IT – Required to learn and use the EHR/EOHR (Medical Practice Electronic System) and its components. As required by the job functions and highlighted in the Policies and Procedures.
Qualifications, Education, and Experience:
- Licensed Registered Nurse from an accredited Nursing Program.
- Graduate from an accredited university with a background in science, including BA or BS in Biology, Chemistry, Nursing, Anatomy and Physiology, Public Health, Behavioral Science, or a similar degree is a plus.
- Two – five years’ experience in a Federally Qualified Health Center or Rural Health Center (clinical) setting preferred.
- Proficient computer skills, including Microsoft Office (specifically Work and Excel)
- Highly organized and well-developed oral and written communication skills.
- Knowledgeable through practical experience and/or training in the areas of:
- Care Coordination
- Case Management
- Clinical Practices
- Community Health
- Joint Commission
- Managed Care
- Maternal and Child Health
- Primary Care Medical Home
- Preventative Care Guidelines
- Public Health
- Self-disciplined, energetic, passionate, and innovative.
- A team player that can follow a system and protocol to achieve a common goal.
- Must be sensitive to the needs of the patients in a community health care setting, in the areas of health and social services as one component.
- Demonstrates sound judgment, decision-making, and problem solving skills.
- Able to maintain confidentiality with all aspects of information in accordance with practice, State and Federal regulations.
- Bilingual in English and Spanish preferred, but not required.
- Must be CPR Certified.
- Must be willing to work at any Omni Family Health location and be amenable to work weekends, if so needed.
- Must obtain a Valid California Drivers License at all times plus proof of insurance, to allow you to be placed in all Omni Family Health clinics if needed.
- Promotes and believes in Omni Family Health mission statement.
- Ability to relate to the public regardless of ethnic, religious and economic status.
Responsible To: Director of Nursing
Classification: Full Time Position, Exempt