Responsibilities:
In conjunction with the clinical Family Medicine team, plans for and ensures the provision of comprehensive health care services for NEVHC patients and families with documented case management needs i.e. ambulatory care sensitive conditions per LA County/PPP protocol, chronic diseases, etc . Coordinates patient referrals to other services such as external specialty care referrals (e.g. OVMC/PMD specialty clinics) and internal specialty care (dental, nutrition, social services). Ensures continuity of care along the continuum of care. Establishes, maintains and updates a patient database of high risk patient cases. Maintains patient follow-up procedures. Establishes a tracking system for follow-up. Determines case closure when patient is lost to follow-up or has completed plan of care. Determines need for reassessment. Tracks patient's attendance at appointments; arranges rescheduling of appointments as needed. Provides case management for at least 150 patient cases at any given time. As part of overall case management, provides counseling and health education to patients and families. Explains treatment and how to care for the patient's needs, performing counseling services, when required. Defers to RN as needed for higher level decision making. In conjunction with the RN Coordinator, facilitates interdisciplinary team conferences as needed to periodically evaluate the effectiveness of the care plan through observation of client's physical condition and behavior, signs and symptoms of illness and reactions to treatment and through communication with patient and other members of the health care team. Acts as the patient's advocate, as circumstances require, by initiating action to improve health care or to change decisions or activities which are against the interests or wishes of the patient, and by giving the patient the opportunity to make informed decisions about health care before it is provided. Documents in patient's chart all progress or case management activities completely, accurately and legibly. Documents telephone conferences and team conferences as per LA County PPP case management protocol. Follows up on abnormal diagnostic tests (lab, x-ray) according to provider's orders or existing clinical protocols. Maintains logs, statistics as needed. Prepares reports or conducts audits as required. Assesses staff development and training needs. Trains staff as needed on programmatic or clinical issues related to care delivery. Participates in the NEVHC Quality Management process through the clinic's Quality Council. Assists in developing and implementing a nursing quality improvement component to monitor the delivery of nursing services in accordance with established policies, procedures and protocols. Conducts inreach or outreach activities as needed. Attends meetings as directed. Participates in UM/QM meetings for managed care patients. Assists with the implementation of clinic policies and procedures as needed within the health center working in concert with other staff to resolve interdepartmental issues, recommending changes in policies and procedures as needed. Participates in all safety programs which may include assignment to an emergency response team. Participates in hazardous waste and infection control assignments as required in the health center which may include being designated as an emergency responder to a hazardous substance release or spill; performing infection control data collection, evaluation, reporting and follow-up as specified in the NEVHC clinical health services policy and procedures manual. Performs other duties as required or as assigned by Supervisor(s).

Qualifications:
Must be a graduate of an accredited school of nursing w/a valid, current CA Registered Nurse license to practice.
Be able to communicate tactfully and empathetically, with cultural sensitivity; with staff and patients. Fluently bilingual Spanish + English strongly preferred.
Two years clinical experience as a Licensed Vocational Nurse, with a minimum of one year of experience in the clinical area assigned. Experiences must have been as a Licensed Vocational Nurse within a United States Licensing Jurisdiction.
Must demonstrate through written and/or oral testing, the knowledge and skills necessary to provide care appropriate to the age of the patients served and has knowledge of the principles of growth and development over the life span. He or she is able to identify and categorize each patients age specific grouping of needs, such as those for infant, adolescent, adult or geriatric patients.
Must possess excellent interpersonal.
Current, valid CA Driver's License, valid vehicle liability insurance, and an available vehicle needed.
Must maintain a current Cardio-Pulmonary Resuscitation certification, in compliance with corporate CPR policy.
Must be willing and able to work a varied and flexible schedule to accommodate the needs of NEVHC and its patients.
Must maintain or exceed competency levels as established by corporate standards for clinical practice