Health Home Project (HHP) Nurse


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. Job Duties: Responsibilities:
  1. Participates in Health Home Project team meetings and quality improvement initiatives.
  2. Facilitates health and disease patient education, including leading group office visits.
  3. Supports patient self-management of disease and behavior modification interventions.
  4. 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.
  5. Coordinates continuity of patient care with patients and families following hospital admission, discharge, and ER visits.
  6. 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.
  7. Conducts comprehensive, preventive screenings for patients and/or assists all support staff in daily patient interactions as needed.
  8. Promotes clear communication amongst care team and treating clinicians by ensuring awareness regarding patient care plans.
  9. Facilitates patient medication management based upon standing orders and protocols.
  10. Participates on a team for data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to the Health Home Project.
  11. Evaluates clinical care, utilization of resources, and development of new clinical tools, forms, and procedures.
  12. Oversight of Medical Assistants in the Health Home Project.
  13. Develop training material and train staff as required.
  14. Assist with Medical Assistant competency upon hire and annually thereafter.
  15. Assists all patients through the healthcare system by acting as a patient advocate and navigator.
  16. Participates in community functions as appropriate.
  17. Assume other responsibilities as required.
Other Duties
  1. 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.
  2. Compliance – Ensure compliance with all local, state and federal regulations.
  3. QA/QI – Participate in QA/QI activities and contribute towards the overall performance improvement of the organization.
  4. 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:
  1. Licensed Registered Nurse from an accredited Nursing Program.
  2. 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.
  3. Two – five years’ experience in a Federally Qualified Health Center or Rural Health Center (clinical) setting preferred.
  4. Proficient computer skills, including Microsoft Office (specifically Work and Excel)
  5. Highly organized and well-developed oral and written communication skills.
  6. 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
  • Pediatrics
  • Public Health
  1. Self-disciplined, energetic, passionate, and innovative.
  2. A team player that can follow a system and protocol to achieve a common goal.
  3. 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.
  4. Demonstrates sound judgment, decision-making, and problem solving skills.
  5. Able to maintain confidentiality with all aspects of information in accordance with practice, State and Federal regulations.
  6. Bilingual in English and Spanish preferred, but not required.
  7. Must be CPR Certified.
  8. Must be willing to work at any Omni Family Health location and be amenable to work weekends, if so needed.
  9. 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.
  10. Promotes and believes in Omni Family Health mission statement.
  11. Ability to relate to the public regardless of ethnic, religious and economic status.
Responsible To:                     Director of Nursing Classification:                        Full Time Position, Exempt