Nurse Navigator

Are you excited about a new and exciting opportunity Do you have a passion for working with families and individuals in need of healthcare housing and community support services Are you interested in working for a missiondriven and innovative organization Well look no further! At Community of Hope we envision Washington DC where everyone is healthy housed and hopeful. If you are ready to make a positive difference in the community this position is for you!

Our mission: To improve health end homelessness and partner with communities to make Washington DC more equitable.

Our Approach and Values:

We celebrate peoples strengths and acknowledge the impact of trauma on peoples 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.

Position Summary: Community of Hope is hiring a Nurse Navigator Population Health. The Nurse Navigator delivers care management and care coordination services based on patientcentered individual care plans to ensure that care is coordinated with patient and across health care providers settings conditions community service providers and caregivers. Additionally the Nurse Navigator Population Health will ensure 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. This is a fulltime position reporting directly to our Lead Nurse Navigator and is based out of our Conway Health and Resource Center in SW D.C..

This salary for this position ranges between $95000 and $105000 annually and the offer amount is determined by the candidates education qualifications and experience. Indeed provides their own estimated salary calculator and is not affiliated with COHs range.

Highlighted Duties and Responsibilities:

• Provides eligible patients with information related to My Health GPS services and answers patient inquiries.
• 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.
• Ensures that care plans are in agreement with provider orders and COH standards of care for chronic diseases.
• Monitors the patients health status and documents progress toward the goals contained in the personcentered plan of care including amending the plan of care as needed.
• Implements the personcentered 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 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 selfcare 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 beneficiary prior to discharge or within twentyfour 24 hours after discharge to support transitions from inpatient to other care settings. Ensures that patients discharged from hosptials have adequate care and support and regularly checks up on progress.
• Communicates regularly with My Health GPS patients via facetoface 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 MHGPS program 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 400 patients in conjunction with other team members.
• Documents all patient interactions in eCW or other systems per policies and protocols.
• Works with Quality Manager supervisor and team members to devise and implement quality management (QM) activities as requested.
• 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/Nurse Navigators 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.*

Minimum Qualifications:

• Bachelor of science degree in nursing required.
• A current unencumbered DC Registered Nurse license with current CPR certification required.
• BLS 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 lowincome populations required.
• Demonstrated ability to function effectively in a team required.
• Willingness to work Saturdays and evenings required.
• Willingness to travel between COH sites or relocate to a different COH site on a full or parttime basis 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.

At COH we understand the toll that the Covid19 pandemic has taken on the workforce which is why we prioritize the following wellbeing and worklife balancecentered benefits:

• Remote work opportunities are available for many of our roles promoting a culture of worklife balance.
• 8hour 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 performancebased 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 wellbeing activities culture compact activities and traumainformed care initiatives
• Medical/Dental/Vision Plans through CareFirst BlueCross Blue Shield
• Life insurance shortterm disability and longterm disability insurance
• 403(b) Retirement Plan
• Flexible Spending Accounts for medical and dependent care reimbursable expenses
• And much more!

About Us:

Community of Hope is a missiondriven innovative and rapidly growing nonprofit. For 45 years we have provided healthcare housing and community support services to make Washington DC more equitable. As a Federally Qualified Health Center we provide medical dental emotional wellness and care coordination services for the whole family at three locations in DC.

Community of Hope also strongly emphasizes maternal and child health with midwifery practice and the only freestanding birth center in DC. In 2024 Community of Hope provided about 50000 medical visits 6300 dental visits and 17000 behavioral health visits for about 16000 patients. Community of Hope is also one of the largest providers of homelessness prevention and housing services for 1600 households1384 families and 220 individualsexperiencing homelessness in DC. Community support through Family Success Center our WIC nutrition centers and perinatal care coordination for pregnant people experiencing homelessness reach hundreds more families. We believe that everyone in DC can be healthy housed and hopeful.

We were selected as one of The Washington Post 150 Top Workplaces in 2024 and 6 other times since 2014 based on feedback from our staff.

To request a reasonable accommodation to complete an employment application or for general questions about employment with Community of Hope contact a Recruiting Coordinator. Email: Phone:. Community of Hope is an equal opportunity employer.