Nurse Navigator - Community of HOPE

• We care for families by providing direct services with a focus on prevention, healing, and wellness. 
• We improve lives by building on families’ strengths, honoring their choices, and taking a whole-family, multi-generational approach. 
• We lead and advocate for system change to address the effects of historical and current racial inequities on health outcomes and housing opportunities. 
• We embrace the diversity of our community, welcome all voices and perspectives, and treat everyone with respect, compassion, and integrity. 
• We strive for excellence in all that we do, implement evidence-based practices, measure our outcomes, and use this knowledge to continuously strengthen our work. 

• Develops the clinical elements of an individual care plan, including a full biopsychosocial assessment of patient needs, in consultation with other health team members.  
• Ensures that care plans are in agreement with provider orders and COH standards of care for chronic diseases.
• 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.
• Implements 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.
• Acts as a liaision 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.
• Counsels patients on the appropriate utilization of health services in order to avoid unnecessary utilization of emergency rooms and hospitals.
• 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 patient within three (3) business days 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 panel of care-managed 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.
• Evaluates the quality of care in care-management panel through a clinical and value lens by assessing appropriate levels of care and support services for patient panel.
• Schedules work load for maximum efficiency.  Manages panel of approximately 150 patients in conjunction with other team members.
• Documents all patient interactions in eCW or other systems per policies and protocols.
• Works with Quality Improvement Manager, supervisor, and team members to devise and implement quality management (QM) activities as requested.
• Inputs and updates data to ensure accuracy of program reports.
• Assists with generating reports which may include analysis of patient populations, efficacy of education, tracking of interventions, UDS reports, etc.
• Coordinates with Clinical Nurse Managers as needed, including in the management of clinically related patient complaints, unusual incident reports, HIPAA and OSHA incidents.
• Complies with all OSHA and Safety guidelines patient complaints, unusual incident reports, HIPAA and OSHA incidents.
• Performs other duties as assigned.

• Bachelor of science degree in nursing required.
• A current, unencumbered DC Registered Nurse license with current CPR certification required. 
• Knowledge of primary care and health maintenance required.
• Experience with educating patients with chronic health conditions preferred. 
• Ability to work with computers and electronic health records required.
• Strong verbal and written communication skills required.
• Strong organizational skills with an ability to multitask required. 
• Demonstrated cultural competence in communicating with low-income populations required.
• Demonstrated ability to function effectively in a team required.
• Ability to travel between COH sites or relocate to a different COH site on a full or part-time basis required.
• Ability to work Saturdays and evenings required.
• Bilingual in Spanish, Amharic, or French preferred.
• Proof of required vaccinations is required.  This includes, but may not be limited to, Flu and Covid. COH will consider requests for reasonable accommodations for anyone who cannot be vaccinated for a religious or medical reason, subject to applicable law.

• 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 
• National Health Service Corps (NHSC) and DC Health Professional Loan Repayment Program (DCHPLRP) participants 
• 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 well-being 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 
• And much more! 

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.