Care Coordination Specialist, Population Health

Care Coordination Specialist, Population Health

Community of Hope is seeking a Care Coordination Specialist, Population Health to help COH patients navigate and connect to appropriate health and wellness resources, public benefit programs, and other social services/community resources in a timely and culturally appropriate manner. This position is located at our Conway Health & Resource Center in SW, Washington, DC.

Our Approach and Values

We celebrate people's strengths and acknowledge the impact of trauma on people's lives.

We embrace diversity, welcome all voices, and treat everyone with respect and compassion.

We lead and advocate for changes to make systems more equitable.

We strive for excellence and value integrity in all that we do.

What You'll Do

• Directly delivers or effectively connects patients to appropriate wellness resources, public benefit programs, and other needed social services/community resources in a timely and culturally appropriate manner, with the goal of addressing social determinants that negatively affect health and wellness.
• Coordinates medical care with patients and across health care providers, settings, conditions, and caregivers, with the goal of reducing unnecessary emergency room utilization, as well as hospitalizations and hospital readmissions.
• Assists Population Health Nursing Staff in collecting information to complete accurate initial biopsychosocial assessments, including interviewing the patient, and gathering data from eCw and outside data sources.
• Works with Population Health Nursing Staff to assist patients in setting short and long term goals, with a particular emphasis on social needs, barriers to care, behavioral health support, medication management, and nutrition. Ensures that this information informs the individualized care plan.
• Attempts to complete in person or telephonic monthly follow-up to one-hundred percent of My Health GPS patients. Follow-up includes an assessment of current medical and social needs, documentation of recent health care interactions, and a status update on individualized care plan goals.
• Works with Population Health Nursing Staff to reach out to patients within 24 hours of a hospitalization or emergency room visit. Documents all patient interactions and billable services in eCW or other systems per policies and protocols. Care coordination activities must be documented at a minimum within the week they are performed, and on the day they are performed whenever possible.
• Provides referrals to community resources, including housing, job training programs, support groups, transportation, child care, etc. Ensures patients complete primary and specialty care appointments by proactively working to resolve patient-identified barriers, making reminder calls, scheduling appointments, arranging transportation, contacting patients following missed appointments, etc.
• Provides education to patients and caregivers regarding health conditions, medication management, healthy lifestyle and chronic disease self-management in a variety of settings, including the waiting room, educational groups, phone calls, and one-on-one meetings.
• Facilitates patient empowerment and engagement by promoting educated, independent patient choice on all aspects of care, including encouraging patients to ask questions and understand the purpose of prescribed treatment and helping patients develop competency in understanding their personal medical information and health conditions.
• Ensures providers have access to accurate and complete medical information at the point of care by proactively requesting hospital and specialist records and utilizing non-COH data sources, including CRISP.
• Other duties as assigned.

Requirements

• At least 2 years of experience in the heath-related field.
• BLS Certification required.
• Commitment to work with underserved populations and ability to work in non-profit environments.
• Demonstrated cultural competence in communicating with low-income populations.
• Demonstrated ability to function effectively in a team.
• Ability to work with computers, including electronic health records.
• Ability to work evenings and Saturday hours.
• Ability to work from other COH locations and travel between COH sites.
• Proof of required vaccinations is required. This includes, but may not be limited to, Flu. COH will consider requests for reasonable accommodations for anyone who cannot be vaccinated for a religious or medical reason, subject to applicable law.

Nice-to-Haves

• BSW or BA in related health field preferred.
• Experience with educating patients with chronic health conditions preferred.
• Excellent interpersonal skills, ability to show empathy, and ability to interact professionally and gain trust within a culturally diverse environment.

Why You'll Love Working Here! At COH, we prioritize the following well-being and work-life balance-centered benefits:

• 8 x Washington Post 150 Top Workplaces winner.
• 8-hour workdays with paid lunch.
• 3 weeks vacation (additional week after two years), 2 weeks sick leave, + 11.5 paid holidays and one personal floating holiday on an annual basis.
• Annual performance-based raises, up to 5% of your annual pay.
• Tuition reimbursement & loan repayment (NHSC & DCHPLRP), Licensing reimbursement & CEU funding.
• Medical, dental, vision, life & disability insurance + 403(b) retirement.
• Leadership development, internal promotions and career growth opportunities.
• A culture grounded in equity, compassion, and well-being.

About Us

Community of Hope is a mission-driven, innovative, rapidly growing nonprofit, and Federally Qualified Health Center. For over 45 years, we have provided health and housing services, perinatal care coordination, and community support services to make Washington, DC more equitable. Community of Hope also strongly emphasizes maternal and child health, with midwifery practice and the only free-standing birth center in DC. We are honored to be one of DC's largest providers of housing and homelessness prevention services for families and individuals throughout DC. Through our Family Success Center, our WIC nutrition centers, and our various partnerships, we have reached hundreds and believe that everyone in DC deserves to be healthy, housed, and hopeful. With the help of our amazing staff, we have successfully provided:

• 50,000+ medical visits
• 6,300+ dental visits
• 17,000+ emotional wellness visits
• 1,384 families and 220 individuals with housing/homelessness prevention services