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Chronic Care Case Manager/License Vocational Nurse
Who we are: La Clínica de La Raza is a community-based health center committed to providing culturally appropriate, high-quality, and accessible health care to the diverse communities of the San Francisco Bay Area. We have spent over 40 years advocating for and creating a health home for those who have been denied access to care. As health care activists, we are dedicated to ensuring individuals without health coverage receive the same level of quality healthcare as those who have it. From our genesis as a community health center in 1971, we understood that we cannot heal our communities without addressing the economic and social factors that affect health. Many times, this requires providing services in other settings to link individuals to our health center for preventive and primary care. Over 90,000 individuals come to La Clínica because it is a welcoming place that addresses the whole person, coordinating and connecting them to a broad network of services to improve and maintain their health and wellbeing. While we are still known for our activism and spirit of social justice, we are also proud to have grown into a sophisticated provider of primary health care services with 35 sites across Alameda, Contra Costa, and Solano counties.
Major Areas of Responsibility include but are not limited to:
- Participate in health coaching including activities such as: medication adherence, counseling patients on healthy behaviors, providing patients with support on self-management goals, and referrals to access a range of healthcare services.
- Update and maintain registry of patients, using a robust tracking system that can follow patients based on panels belonging to individual primary providers OR disease/condition such as HIV, Hypertension, Diabetes, Coronary Artery disease, etc.
- Assist in training and support Medical Assistants in panel management.
Commitment to Quality:
- Systematically review registries for target populations/panels, conduct predetermined interventions agreed upon by the health care team, and perform coach visits with patients including strict adherence guidelines and documentation.
- Contribute to quality improvement efforts by providing feedback and progress reports to Site Improvement Teams on health status and outcomes of panels.
- Collaborate with other health care team members, such as health educators or BMS, to support individual or group-based interventions of care.
General Office Duties:
- Enter data and manage its integrity for patient registries by conducting data cleanup, running periodic reports, and confirming the accuracy of electronic registry records.
- Carry out provider/health care team orders (consistent with level of training). Activities may range from messenger functions such as ordering labs, or performing INRs, A1C testing, scheduling appointments, coordinating referrals, or may include more complex health coaching visit responsibilities using standing orders to address common problems.
- Attend section meetings and other meetings that support the job responsibilities.
Knowledge:
- Knowledge of chronic care model, fundamentals of health education, motivational interviewing, and supporting patients with self-assessment goals desired.
- Proficient in managing patient databases and other computer software programs such as Excel, Outlook, and practice management systems.
Abilities:
- Self-driven individual with the ability to work independently and exercise good judgment; also able to work effectively with teams, demonstrating willingness to collaborate to improve services, care management, and data processes.
- Ability to protect and maintain strict confidentiality and accurate and detailed patient medical information.
- Demonstrated ability to work and communicate with people from various ethnic, socio-economic, educational, and experiential backgrounds.
- Ability to work courteously and effectively as a team member to support the quality/efficiency standards established for the clinic.
Experience:
- Requires a valid license to practice as a Vocational Nurse in the State of California.
- One to two years' experience in an outpatient facility working with adults and children.
- Must hold a current BLS (Basic Life Support) Certificate. You will have a 30-day grace period to obtain your certificate from the date of hire.
- Experience working with patients in the capacity of health promotion, with knowledge of medical terminology, chronic health conditions, and health coaching.
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