Job Description

Req No.
Regular Full-Time
Health Promotion Center
40 hrs/wk (M-F 8am to 5pm)


Vista Community Clinic is a private, non-profit, multi-specialty outpatient clinic providing care in a comprehensive, high quality setting. Located in San Diego, Orange and Riverside counties, we work to advance community health and hope by providing access to premier health services. We are looking for dedicated, motivated, enthusiastic team players who want to make a difference in the community. Our competitive compensation and benefits program includes health, dental, vision, company-paid life, flexible spending accounts and a 403(B) plan, for eligible employees. VCC is an equal opportunity employer.


Provide consultant and clinical support to Complex Care Coordinators within the guidelines of the Nurse Practice Act. Review complex care patient’s Health Action Plans (HAPs). Facilitate access to primary care and behavioral health clinicians, as needed to assist complex care coordinators to achieve the goals of Vista Community Clinics (VCC) Health Homes Program (HHP). Provide direct care management services to highest need complex care coordinated patients who are at the highest risk for health deterioration or poor health outcomes by developing and implementing a comprehensive care plan to embrace the patients’ strengths, needs, and preferences

  • In a clinical consultant role for the Health Homes Program:
  • Review health action plans.
  • Serve as a clinical resource for complex care coordinators as needed.
  • Facilitate access to primary care and behavioral health clinicians, as needed to assist complex care coordinators.
  • Manage the HHP patient caseload, according to mandated program requirements to ensure compliance with timely completion of care planning, follow-up activities, and documentation and submission timeframes.
  • Ensure HHP staff provide the highest quality of care and are in compliance with the program requirements.
  • Oversee and facilitate patients’ Health Homes Program (HHP) services.
  • Assist in monitoring the allocation and utilization of staff. Monitors quality of service and utilization standards and assumes specific responsibility for patient care.
  • Ensure patients receive quality care by reviewing documentation, making visits with staff, reviewing care plans, conducting/participating in multidisciplinary team conferences,
  • Assist in developing, implementing, and maintaining quality assurance and utilization management standards.
  • Works with outside entities to achieve optimal patient care across the continuum.
  • Works with health care providers to coordinate interdisciplinary approach to providing continuity of care, including utilization management.
    Assist Complex Care Coordinators in implementing VCC patients’ Health Action Plans (HAPs).
  • Assist in the coordination and facilitation of systematic case reviews (SCRs).
  • For most complex HHP members, develop an individualized comprehensive plan of care integrating primary care and community support services to achieve health goals designed to improve functional status, health status, and/or prevent decline.
  • Coach patients using positive reinforcement and encouragement and a flexible approach to address critical issues to help patients develop achievable self-management care plan goals, presenting new skills using a step-by-step process.
  • Support patients in the development of health care goals by conducting a needs assessment process that uncovers a comprehensive physical, mental, and social service needs.
  • Visit patients in their homes or other settings and complete a patient interview on health condition knowledge and motivation to engage in self-management, as needed for most complex HHP patients.
  • Identify and initiate referrals for social service programs; such as financial, community and state supportive services alleviating housing instability and homelessness.
  • Provide a complete continuum of quality care through close communication with patients via in-services systems, and transitions of care; identify barriers to goals and support patients and/or caregivers through advocacy to ensure patient needs and choices are fully represented and supported by their care team.
  • Share options for accessing care and services, and monitor referrals, gaps in care, and follow-up appointment reminders to ensure needed services and supports are offered and accessed.
  • Monitor medication adherence to include medication management and reconciliation periodically for changes, especially at time of care transitions.



  • Current California RN license and good standing with the Board of Registered Nurses.
  • Current CPR certification which includes in-person certification and test on resuscitation models.
  • Minimum three years’ experience in acute care nursing, comprehensive urgent care and/or outpatient clinic

Preferred Qualifications

  • Bilingual English/Spanish
  • Experience with comprehensive care coordination of patients with chronic conditions and complex medical & social needs

Required Skills/Knowledge/Abilities

  • Current knowledge of principles, techniques and procedures used in professional nursing;
  • Basic knowledge of community resources available to provide patient care and follow-up; federal, state, and local laws and regulations governing professional aspects of nursing
  • Demonstrated critical thinking and leadership skills; appropriate role modeling
  • Ability and willingness to work flexible hours, including evenings and weekends
  • Excellent verbal and written skills necessary for communication with patients/clients, providers and other staff
  • Ability to interface with all levels of personnel in a professional manner
  • Ability to work with people of all social and ethnic backgrounds and within the constraints of government funded programs
  • Ability to work independently, take initiative and be proactive
  • Ability to analyze, prioritize and meet deadlines
  • Ability to track and manage time effectively
  • Ability to plan and facilitate internal and community meetings
  • Ability and willingness to meet the organization’s attendance and dress code policies
  • Ability and willingness to conduct patient home visits, when indicated.
  • Ability to handle confidential materials and information in a professional manner
  • Excellent customer service skills and commitment to providing the highest level of customer satisfaction
  • Experience/familiarity with computers, Microsoft Office products (Word/Excel), business e-mail, communication systems and internet search capabilities
  • Willingness to learn and use new computer programs/applications.
  • Familiar with operation of telephone, fax and copier equipment

Application Instructions

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