La Comunidad Hispana (LCH), Kennett Square, offers a comprehensive scope of healthcare, social services, outreach, and education programs for Latinos and other low-income, underserved families living and working in Southern Chester County. As a Federally Qualified Health Center Patient-Centered Medical Home, LCH provides integrated person-centered care in a bilingual and bicultural environment that encourages compliance and fosters improved patient outcomes. Using a holistic approach to care, LCH integrates healthcare with supportive services and education to empower patients to stay healthy, build strong families and lead productive fulfilling lives.
The primary function of the Registered Nurse is to provide chronic care management to high-risk patients, perform triage (phone and in-person) and assist in the care of chronic and primary care patients.
This position is eligible for the NURSE Corps Loan Repayment Program. The program provides loan repayment in exchange for employment in critical shortage areas, such as LCH. More information is available at: http://www.hrsa.gov/loanscholarships/repayment/nursing/
Essential Duties and Responsibilities
TEAM BASED CARE:
Team base care is the provision of patient-centered comprehensive healthcare by a core interdisciplinary team of healthcare professionals, including the Provider, Registered Nurse, Medical Assistants, Member Relation Specialists, and ancillary services. Team based care for the Registered Nurse includes motivational interviewing, healthcare coaching, chronic disease and population health management, and management and supervision of unlicensed staff.
Chronic Care Management
- Manage an empaneled group of patients (per assigned team).
- Huddle with entire core team daily to discuss the day or week’s patients and separately on at least a monthly basis to review high risk clients and goals.
- Case Management: Establish / Maintain a tracking system of all empaneled chronic care patients, assist in developing established care plans, follow up and retrieval of specialty appointment correspondence.
- Test and referral tracking and follow up.
- Provide education to all patients having chronic illness to further patient understanding of condition and treatment choices, with an emphasis on patients with diabetes, hypertension, asthma, hyperlipidemia and history of ischemic vascular disease.
- Manage patients enrolled in medication assistance programs (e.g. GSK’s Bridges to Access) in collaboration with Social Assistance.
- Provide individual education and shared decision-making sessions with patients identified as high risk for hospitalization or emergency room visits as referred to RN by Provider.
- Review transition of care (TOC) documentation from hospital admissions and ER utilizations. Follow-up of all TOC patients within 2 business days. Assist with needed referrals, appointments with specialists, reinforcement of discharge plan, and assist the patient in making medical/nursing follow-up visits.
- Communicate with home health agencies and other community services when applicable to facilitate access for patient and/or family
Population Health management
- Population health management involves interdisciplinary collaboration and management of health outcomes for entire communities or populations with an emphasis on reduction of healthcare disparities and consideration of social determinants of health affecting the community.
- Triage patients over the phone and in-person (walk-in patients).
- Provide direct services as outlined under the protocols for preventative health care starting from newborn through adult.
- Conduct patient education for patients and families of all ages for acute and chronic conditions.
- Blood pressure checks.
- Point of Care testing.
- Administration of vaccines for nurse visit.
- Administer spirometry testing as ordered by Provider.
- Manage patient medication refills and renewal of medication assistance.
- Participate in community outreach, flu clinics, and education programs as requested.
Management & Supervision
- Supervision of students in Medical Assistant and Nursing student interns/externs.
- Supervision and delegation to Medical Assistants as needed.
- Special project or projects depending on the needs of the organization as determined by Medical Director or Nurse Advisor.
- Travel between LCH locations as needed and depending on role responsibilities as well as for routine organization meetings. This includes Kennett Square, Oxford, and Jennersville locations as well as potential future sites as the organization grows.
- Maintains regular attendance; arrives to work on time; performs all duties in a timely manner with special attention to duties with a specific time window for completion per LCH policies and procedures; attends all meetings as scheduled and/or directed by supervisor or CEO.
- Follows all LCH procedures and adhere to policies as outlined in the Employee Handbook.
- Collaborates with staff of all LCH programs including Community Resource Center, Behavioral Health, Social Services and Education as appropriate to ensure efficient integration of services and support.
- Respects confidentiality at all times as outlined in LCH policies and procedures and HIPAA guidelines.
- Performs other duties as assigned. Job description subject to review and may change based on business necessity.
- Graduate from an accredited School of Nursing with a Bachelor’s of Nursing Degree.
- Holds current or eligible for RN license in the Commonwealth of Pennsylvania.
- Public Health/Community health experience is preferred.
- Experience working with a second culture is preferred.
- Holds current CPR certification.
- Maintains current nursing continuing education credits as mandated by the state of PA, including child abuse recognition and training.
- Bilingual: proficient in English and Spanish.
- Proficiency in office-based applications: EMR (experience with Centricity preferred), MS Office (Word, Excel, Access, Power Point, Outlook) and internet use is required.
- Must possess superior organizational skills, the ability to multi-task, and be detail-oriented.
- Customer service and therapeutic communication skills (patient, empathetic, responds to patient’s emotional state, excellent patient interview and history taking skills).
- Excellent written and verbal communication skills are required.
- Must have excellent interpersonal skills and the ability to be a team player.
- Must be capable of employing time-management skills for projects with varying timelines; must be able to work under pressure.
- Must emulate LCH mission and values in working with patients and staff.
LCH is a culturally competent, bilingual, bicultural agency. Qualified members of the community are encouraged to apply.
La Comunidad Hispana (LCH) offers a comprehensive scope of healthcare, social services, outreach, and education programs to low income, underserved families living and working in Southern Chester County. As a Federally Qualified Health Center and Patient-Centered Medical Home, LCH provides fully integrated person-centered care in a bilingual and bicultural environment that encourages compliance and fosters improved patient outcomes. Using a holistic approach to care, LCH changes lives by serving southern Chester County as the leading provider of integrated health and community services.
(if you already have a resume on Indeed)