Chronic Care Case Manager, Lead

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 the many that have been denied access to care. As health care activists, we are dedicated to making sure individuals who do not have health coverage get 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 also addressing the economic and social factors that affect health. Many times, this requires that we go outside and provide services in other settings to build the bridge that links 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.

Be part of an excellent care team: We are looking for Licensed Vocational Nurses who are inspired to deliver a great experience to our patients and who want to play an important role in patient-centered care by performing at the top of theirs cope of practice. At La Clínica, you will be challenged to be exceptionally accurate, observant and an efficient task-master while at the same time providing a human touch and an excellent overall patient experience. Many people excel at one of these areas, but it takes someone with a special combination of skills and character to do both. To be successful, you need to enjoy interacting with all kinds of different people, to feel energized by a fast-paced clinic environment and remain cool under pressure even when serving a person who is upset, disrespectful or impatient. You should have a successful history of being responsible, reliable and capable of solving problems while being friendly and helpful in looking for ways to support other care team members.

Major Areas of Responsibility include but are not limited to

Patient Care

• 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 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, to conduct predetermined interventions agreed upon by health care team and performing 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 accuracy of electronic registry records.
• Carry out provider/health care team orders (those 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 and may use standing orders to address common problems.
• Attend section meetings and other meetings that supports the job responsibilities.

Knowledge

• Knowledge of chronic care model, fundamentals of health education, motivational interviewing and supporting patients with self-assessment goals desired
• Proficient managing patient databases and other computer software programs such as Excel, Outlook, and practice management systems

Abilities

• Self-driven individual with 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 detail patient medical information.
• Ability to work across cultures and demonstrate support of diversity, equity and inclusion.
• 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 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.
• Bilingual English/Spanish required