Community Health Outreach Manager / RN

Southern Indian Health Council, Inc•Alpine, CA

46d•$78,221 - $131,358

About The Position

Under the supervision of the Nursing Supervisor, the Community Outreach Nursing Manager (CONM) works in an integrated manner with the Medical Department and the Community Health Outreach Services (CHS) Department to participate in a broad range of clinical activities. This nurse must be capable of performing patient assessments and developing nursing care plans within the scope of the care provided by the clinic. This nurse also works to identify opportunities for community health improvement and develops activities targeted at the population served by the clinics thus identified. The will also participate in community health events, providing both nursing assessments when indicated, and educational activities. As part of development of a Patient Centered Medical Home, the nurse works with patient care teams led by physicians to identify opportunities for case management as defined in specific job duties. The CONM provides information for individuals, families and communities in health promotion and disease prevention of chronic and other disease.

Requirements

Must have a current California Registered Nurse and keep current.
Experience in the nursing field as well as the public health field, home health, or community health for at least (2) years required.
Must be 18 years of age or older
A valid California driver’s license is required at the time of appointment and must be maintained throughout employment.
Applicant must be insurable under SIHC vehicle insurance policy at the time of hire and throughout employment.
Certifications and/or licenses appropriate to the positions required education and profession must also be valid and maintained.
Applicants must have a reputation for honesty and trustworthiness.
Must be responsible and able to exercise good judgment, accept administrative supervision, pay attention to detail, follow instructions, including the ability to interact effectively and communicate with people in a professional and courteous manner.
Must be highly confidential and work as a team with other staff.
Applicant should be sensitive to client’s needs.
Strong supervisory, leadership, team building, interpersonal, and organizational skills.
Ability to establish and maintain effective peer relationships with coworkers within the Medical Department, clinic-wide, and the public.
Must be able to express ideas clearly, concisely, address audiences effectively, and exercise balanced judgment in evaluating situations and making decisions.
Willing to be part of a team and cooperate in accomplishing department goals and objectives.
Ability to prioritize, meet deadlines, take initiative, be proactive, and function in a rapidly changing environment.
Ability to work with people of all social and ethnic backgrounds and to resolve conflicts, negotiate situations, and facilitate consensus.

Responsibilities

Provides supervision to ROAM medical staff, Senior Services Coordinator, Community Health Representatives, and the Patient Advocate.
Conducts planned comprehensive and focused assessments, including functional assessments of seniors and other specific populations, defines and prioritizes patient, family, practice, community needs, and problems using a wide range of data collection methods.
Develops Care Plans in conjunction with patient’s physician(s), ensuring that patient needs are identified and addressed within the scope of clinic responsibility, also assists with coordination of care with outside entities, such as Case Management of health plans, hospitals, and et.al.
Ensures that patient care plans are discussed with patients, with agreement and clarity as to goals and expectations with patients as center of focus.
May perform home visits to identified patients with limited access to care who are homebound or functionally homebound to assess needs, home safety, and et.al. This information is used to develop the Care Plan for the patient described above. May perform periodic home assessments within the scope of licensure (i.e. SIHC is not a licensed Home Health Agency, and skilled nursing care in the home is not provided). Evaluates the effectiveness of the plan and revises as appropriate.
Works with the Medical Director and other staff to identify patients supported through the Special Diabetes Program for Indians (SDPI), identifying opportunities to improve care and ensure that evidence based medical interventions are provided as indicated.
Uses the electronic health record, maximizing use for the purposes of maintaining a comprehensive medical record, including documentation of all patient interactions; and also utilizes the EHR for access to resources as needed for patient care.
Counsels patients and families regarding physical and psychosocial adjustments to illness/treatment.
May assist with scheduling tests and therapies for patients in need as part of completing doctor’s orders for patients.
Identifies possible needs for referral of patients to community programs, specialty providers, etc. and discusses with patient’s physician as part of care planning.
Collaborates with medical and family services directors in the development of case management of acute and long-term medical or psychosocial needs of the patient.
Collaborates with physicians, clinical, and pharmaceutical staff to assess, plan and implement strategies to advance clinical practice and educational needs of patients and staff.
Helps identify inpatient census for clinic patients, to allow for appropriate Transition Management on discharge, to ensure outpatient follow up on a timely basis, minimizing risk of poor outcomes or avoidable re-admission.
Applies nursing intervention and procedures designed to prevent and control disease as required by local health organizations.
Evaluates patient outcomes and community interventions and monitors progress to assess need for corrective action.
Works in conjunction with the Medical Director and clinical staff to monitor effectiveness of interventions, processes and programs such that a continuous quality improvement process is in place.
Attends staff meetings, in-services and appropriate courses to maintain personal and professional growth.
Participates in community activities, committees, workshops and seminars as assigned by Medical Director.
Maintains a client/patient roster that includes activities and services provided.
Works as part of team, and helps lead efforts to provide health coaching with an emphasis on illness prevention and health promotion activities.
Submits written reports and documentation of services to the Medical Director for distribution by the Medical Director to requested funding sources through and the SIHC Fiscal Department.
Maintains patient confidentiality.
Maintains current practice guidelines for the clinic.
Fosters team work; demonstrates ability to communicate with and work with staff and other departments.
Supervises Community Health Representatives, ROAM medical staff, Patient Advocate, Senior Services Coordinator navigator under direction of the Nursing Supervisor.
Ability to work a flexible schedule.
Performs other duties as assigned.