Nurse Navigator, Population Health

Nurse Navigator

Community of Hope is seeking a Nurse Navigator to serve as a vital facilitator among patients, health care providers, community service providers, and caregivers. The Nurse Navigator will deliver care management and care coordination services based on patient-centered, individualized care plans, ensuring that overall patient care is coordinated seamlessly and appropriately. This position is located at our Marie Reed Health Center in NW, 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

• Ensures that My Health GPS (MHGPS) patients receive all appropriate care coordination and case management services, including appropriate care transition planning, patient education, and social service referrals and linkages, in a timely and culturally appropriate manner with the goal of reducing unnecessary emergency room utilization, as well as hospitalizations and readmissions.
• Develops the clinical elements of an individual care plan for My Health GPS patients, including a full biopsychosocial assessment of patient needs, in consultation with other health team members.
• Implements the person-centered plan of care through appropriate linkages, referrals, and coordination with needed services and supports.
• Monitors the patient's health status and documents progress toward the goals contained in the person-centered plan of care, including amending the plan of care as needed.
• Acts as a liaison between patients and caregivers, providers, clinical staff, specialists, and other health care professionals.
• 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 condition, medications, and self-care skills.
• Coordinates transitions between healthcare providers and settings in order to reduce emergency department and inpatient admissions, readmissions, and length of stay.
• Conducts outreach to the beneficiary prior to discharge or within twenty-four (24) hours after discharge to support transitions from inpatient to other care settings. Ensures that patients discharged from hospitals have adequate care and support and regularly checks up on progress.
• Communicates regularly with My Health GPS patients via face-to-face or telephone encounters at least once per month, as well as via the patient portal. Meets patients where necessary in order to accomplish this goal.
• Schedules work load for maximum efficiency. Manages panel of approximately 400 patients in conjunction with other team members.
• Performs other tasks as requested by supervisor.

Requirements

Must-Haves

• Bachelors of Science degree in Nursing.
• A current, unencumbered DC Registered Nurse license with current CPR certification.
• Active BLS Certification.
• Knowledge of primary care and health maintenance.
• Ability to work with computers and electronic health records.
• Strong verbal and written communication skills.
• Strong organizational skills with an ability to multitask.
• Demonstrated cultural competence in communicating with low-income populations.
• Demonstrated ability to function effectively in a team.
• Willingness to work Saturdays and evenings. Willingness to travel between COH sites or relocate to a different COH site on a full or part-time basis.
• 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

• Experience with educating patients with chronic health conditions.
• Bilingual in Spanish, Amharic, or French.

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