Patient Care Advocate

About Us
At Community of Hope, we are a mission-driven, innovative, and rapidly growing nonprofit organization. For over 40 years, we have provided healthcare, housing, and supportive services for under-resourced, underserved communities in Washington, DC. As a Federally Qualified Health Center, we offer medical, dental, emotional wellness, and care coordination services for the whole family at three locations in DC.

We emphasize maternal and child health, with midwifery practice and the only free-standing birth center in DC. In 2020, we provided about 28,400 medical visits, 7,000 dental visits, and 10,000 behavioral health visits for approximately 11,000 patients. We also offer community walk-in COVID testing and COVID vaccines.

Our organization is committed to improving health and ending family and individual homelessness to make Washington, DC, more equitable.

Company Overview
We care for families and individuals by providing direct services focusing on prevention, healing, and wellness. We improve lives by building on families' and individuals' 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 strive for excellence in everything we do, implement evidence-based practices, measure our outcomes, and use this knowledge to strengthen our work continuously. We were selected as one of The Washington Post 150 Top Workplaces in 2014, 2016, 2017, 2018, 2020, 2021, and 2024 based on feedback from our staff.

Job Description
We are seeking a Lead Nurse Navigator, Population Health, to join our team. This full-time position reports directly to our Associate Director of Nursing Care Management and is based out of our Conway Health & Resource Center in SW, DC.

The salary for this position ranges between $100,000 and $110,000 annually, determined by the candidate's education, qualifications, and experience. Indeed provides an estimated salary calculator, but it is not affiliated with our range.

In this role, you will lead the Nurse Navigator team while managing the day-to-day effectiveness of the care management service delivery model. You will evaluate program outcomes and individual staff productivity and performance, ensuring high-quality care management for our patients.

You will deliver comprehensive care-management services, including transition of care planning, patient education, and social service referrals and linkages, in a timely and culturally appropriate manner through a patient-centered team-based care mode. This includes developing clinical elements of individual care plans, monitoring patient health status, and documenting progress toward goals contained in the person-centered plan of care.

You will work closely with health care team members within and outside of Community of Hope, including caregivers, to ensure continuity of care and reduce fragmentation, duplications, and gaps in treatment. You will also facilitate patient empowerment and quality of life by promoting educated, independent patient choice on all aspects of care.

This position requires strong verbal and written communication skills, as well as organizational skills with the ability to multitask. You must be able to work with computers and electronic health records, and possess demonstrated cultural competence in communicating with low-income populations. A bachelor of science degree in nursing and a current, unencumbered DC Registered Nurse license are required.

Responsibilities
* 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 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.
* 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.
* 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, within a COH facility, 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 own patient panel and panels of all Nurse Navigators.
* Schedules workload 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.
* Responsible for creating an environment of patient-focused care through leadership of the Nurse Navigator team.
* Collaborates with Population Health Director to define standards for quality care management and adequate documentation.
* Establishes level of documentation criteria to maximize reimbursement opportunities.
* Meets with supervisees regularly and provides ongoing feedback and support, including opportunities for professional development.
* Approves supervisees' time sheets per the established payroll deadlines.
* Reviews the performance of team members in a timely manner, including completing 90 day and annual performance evaluations per their due dates and documenting any issues or changes.
* Complies with and helps to enforce standard organizational policies and procedures as described in the COH toolbox, including but not limited to the employee handbook, the Accounting Manual, and other COH policies and procedures.
* Partners with the Talent Management team regarding personnel matters including but not limited to performance management, terminations, leaves of absence, recruiting, training, and onboarding.
* Attends Leadership Institute trainings as needed or as required.
* Handles sensitive information with care and discretion to ensure confidentiality.
* Promotes the 'One Community, One Hope' culture through participating in quarterly culture initiatives and implementing teambuilding activities or creating other opportunities that promote a positive workplace culture.

Requirements
* Bachelor of science degree in nursing required.
* 1-2 years of supervisory experience preferred.
* 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.

Benefits
We prioritize well-being and work-life balance-centered benefits, including remote work opportunities, 8-hour workdays with paid lunch, 11.5 paid company holidays, 15 days of paid vacation (increasing to 20 after 3 years of service), and 12 days of paid sick leave on an annual basis. We also offer 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.

Additionally, we offer many opportunities for internal promotions and transfers across the agency as we continue to grow, averaging 30+ promotions each year. We provide 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.

We offer a comprehensive benefits package, including 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.

---