Job Description

• Develops the clinical elements of an individual care plan for enrolled patients in consultation with other health team members and in line with COH standards of care.
• Monitors the patient’s health status and documents progress toward the goals contained in the plan of care, including amending the plan of care as needed.
• Works with care coordinators to implement the person-centered plan of care through appropriate linkages, referrals, and coordination with needed services and supports.
• Works with health care team members within and outside of COH, including caregivers, to ensure continuity of care and reduce fragmentation, duplications, and gaps in treatment.
• Facilitates patient empowerment and quality of life by promoting educated, independent patient choice on all aspects of care.
• Provides education to patients and caregivers to allow them to better understand health conditions, medications, and self-care skills.
• Counsels patients on the appropriate utilization of health services in order to avoid unnecessary utilization of emergency rooms and hospitals.
• Coordinates transitions between healthcare settings in order to reduce emergency department use, inpatient admissions, and readmissions. Ensures that patients discharged from hospitals have adequate care and support.
• Coordinates with Clinical Nurse Managers/Nurse Navigators as needed, including in the management of clinically related patient complaints, unusual incident reports, HIPAA and OSHA incidents
• Communicates regularly with enrolled patients via face-to-face or telephone encounters at least once per month, as well as via the patient portal. Meets patients were necessary in order to accomplish this goal.
• Contributes to the creation and refinement of key programmatic elements, including assessments, care plans, patient education materials, and protocols.
• Complies with all OSHA and Safety guidelines patient complaints, unusual incident reports, HIPAA, and OSHA incidents.
• Assists the Director of Population Health Services in evaluating the quality of care in the program through a clinical and value lens and implements quality improvement processes to achieve desired outcomes.

• Bachelor of Science degree in Nursing required.
• A current, unencumbered DC Registered Nurse license with current CPR certification is required.
• Primary care experience preferred.
• Care management and patient education experience preferred.
• Experience working with patients with substance use disorders and behavioral health concerns is preferred.
• Knowledge of chronic disease processes and health maintenance is required.
• Demonstrated cultural competence in communicating with low-income populations required.
• Ability to work with computers and electronic health records required.
• Strong verbal and written communication skills are required.
• Proof of COVID-19 and Booster (if eligible) is required.

• Remote work opportunities are available for many of our roles, promoting a culture of work-life balance
• 8 hour workdays, which include a paid lunch
• 11.5 paid company holidays, 1 personal floating holiday, 15 days of paid vacation (increases to 20 after 3 years of service), and 12 days of paid sick leave on an annual basis
• Annual performance based raises, up to 5% of your annual pay
• Tuition reimbursement, loan repayment for clinicians, licensing reimbursement, and continuing education unit funds for licensed staff
• Many opportunities for internal promotions and transfers across the agency as we continue to grow; we average 30+ promotions each year
• Ongoing internal leadership training for supervisors
• Diversity, equity, and inclusion training and initiatives for all staff
• Ongoing wellbeing activities, culture compact activities, and trauma informed care initiatives
• Medical/Dental/Vision Plans through CareFirst BlueCross Blue Shield;
• Life insurance, short-term disability and long-term disability insurance;
• 403(b) Retirement Plan;
• Flexible Spending Accounts for medical and dependent care reimbursable expenses;
• Transportation pre-tax payroll deduction for metro;
• Tuition Reimbursement for graduate studies;
• Employer paid lunch time;
• And much more!

About communityofhopedc.org:

Community of Hope is a mission-driven, innovative, and rapidly growing nonprofit. For nearly 40 years, we have provided healthcare, housing, and supportive services for low-income, underserved, and homeless people in Washington DC. As a Federally Qualified Health Center, we provide medical, dental, behavioral health, and care coordination services for the whole family at three locations in DC. Community of Hope also has a strong emphasis on maternal and child health, with a midwifery practice and the only free-standing birth center in DC. In 2020, Community of Hope provided about 28,400 medical visits, 7,000 dental visits, and 10,000 behavioral health visits for about 11,000 patients. Community of Hope is also providing community walk-in COVID testing and COVID vaccines. Community of Hope is also one of the largest providers in DC of housing and support services for families experiencing homelessness. Through providing these programs, we live out our mission to improve health and end family homelessness to make Washington, DC more equitable.

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