Integrated Internal Medicine Nurse
29 days ago
Dallas
Job DescriptionJob Title: Integrated Internal Medicine NursePosition Summary The Integrated Internal Medicine Nurse provides high-quality, patient-centered nursing care in HHM Health’s Integrated Internal Medicine Department. This role is central to our integrated care model, ensuring that patients receive coordinated services across Internal Medicine, Behavioral Health, Pharmacy, Nutrition, Vision, Women’s Services, Psychiatry, and Dental care. The nurse collaborates closely with physicians, residents, advanced practice providers, Community Health Workers (CHWs), and the Health Operations team to deliver seamless, team-based care. By combining clinical expertise with care navigation, this role helps patients achieve better outcomes and ensures alignment with HHM Health’s quality and performance goals. Key Responsibilities • Provide direct outpatient patient care, including assessments, immunizations, medication administration, wound care, and health screenings., • Collaborate with physicians, residents, nurse practitioners, and physician assistants in managing acute and chronic conditions, ensuring patients are connected with appropriate integrated services., • Work closely with Community Health Workers to address non-medical determinants of health, connect patients to resources, and ensure continuity of care beyond the clinic., • Facilitate interdisciplinary coordination with Behavioral Health, Nutrition, Pharmacy, Dental, and Vision teams to deliver comprehensive, whole-person care., • Educate patients and families on treatment plans, preventive health practices, and chronic disease management, reinforcing the importance of integrated services., • Proactively identify and close care gaps through patient outreach, follow-up, and accurate documentation to support HEDIS and UDS quality performance measures., • Triage patient calls, walk-ins, and urgent concerns, directing patients to appropriate outpatient services in a timely manner., • Support Internal Medicine residents by modeling integrated outpatient workflows and patient-centered practices., • Coordinate referrals and follow-up visits exclusively within the outpatient clinic setting, ensuring patients experience smooth transitions across HHM Health service lines., • Actively participate in outpatient team huddles, quality improvement initiatives, and integrated case reviews., • Maintain compliance with HHM Health’s policies, infection control standards, and outpatient regulatory requirements.Examples of Integrated Outpatient Workflows, • Diabetes Care: Coordinate care for a patient with diabetes by administering A1C tests, arranging a same-day consultation with the Nutritionist, ensuring medication adjustments through Pharmacy, and connecting with a CHW., • Hypertension Management: Monitor blood pressure during visits, enroll the patient in remote BP monitoring if needed, collaborate with Behavioral Health for stress management, and ensure the patient follows up with Pharmacy for medication reconciliation., • Preventive Care: Review preventive screening needs (mammogram, colonoscopy, eye exam), coordinate scheduling across service lines, and reinforce education with support from CHWs., • Behavioral Health Integration: Identify patients with depression or anxiety during Internal Medicine visits, facilitate warm handoffs to Behavioral Health providers, and ensure follow-up is tracked and closed.Qualifications, • Current unrestricted Registered Nurse (RN) license in the state of Texas (BSN preferred)., • Minimum of 2 years of nursing experience in an outpatient internal medicine, adult medicine, or integrated primary care setting preferred, but not required., • Experience in a Federally Qualified Health Center (FQHC) or residency training clinic preferred but not required., • Strong understanding of outpatient integrated care models, chronic disease management, and interdisciplinary collaboration., • Familiarity with HEDIS/UDS quality measures and performance improvement strategies., • Excellent communication, organizational, and patient education skills., • Ability to work effectively with physicians, residents, APPs, Community Health Workers, and other support staff in a team-based model., • BLS certification required; ACLS certification preferred.Working Conditions, • Full-time, outpatient-only role. At HHM Health, the health and well-being of our employees matters just as much as that of our patients. We offer free employee coverage for vision, dental, and life insurance; and competitive medical premiums. We also offer a medical reimbursement account to cover up to 85% of out-of-pocket medical costs for medical family coverage (up to 70% for individual coverage). Additionally, our full-time employees are eligible for the following: • 403(b) retirement savings plan with dollar-for-dollar matching up to 3% and match 50% of the next 2% (contribute 5% to get 4% matched). 100% vested upon enrollment., • Generous paid time off plan for full-time employees (includes Sick and Volunteer Days), • Paid Holidays, • Accidental Death & Dismemberments (ADD) plan, • Short-term & Long-term Disability, • Employee Assistance Programs (EAP) At HHM Health, our mission is to provide quality healthcare to all its neighbors with love, compassion, and respect. Our vision is to be the best patient-focused health center providing personalized physical, mental, and spiritual care for every individual. We are led by our CARES Values (Compassion, Advocacy, Respect, Excellence, Servant Heart). Together, our patient care teams are providing quality healthcare to the uninsured and underinsured communities in Dallas and surrounding counties. Equal Opportunity Employer HHM Health is committed to providing equal employment opportunity to all individuals regardless of their race, color, religion, gender identity and expression, age, sexual orientation, national origin, disability, veteran status, marital status, or any other characteristic protected by federal, state or local law. HHM Health hires and promotes based solely on the qualifications of the individual and the essential functions of the job being filled.
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