Position Summary: Community of Hope is looking for a passionate and innovative Nurse Navigator. This position will work primarily with an underserved community and will combine nurse care management and care coordination services for patients with complex medical and social needs. The nurse is the clinical lead in the development of patient-centered individual care plans to ensure that care is coordinated with patients across health care providers, settings, conditions, community service providers, and caregivers. This is a full-time position. Highlighted Duties and Responsibilities: Develops the clinical elements of an individual care plan for enrolled patients in consultation with other health team members and in line with COH standards of care. Monitors the patient’s health status and documents progress toward the goals contained in the plan of care, including amending the plan of care as needed. Works with care coordinators to implement 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. 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 conditions, 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 settings in order to reduce emergency department use, inpatient admissions, and readmissions. Ensures that patients discharged from hospitals have adequate care and support. 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 Communicates regularly with enrolled 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. Contributes to the creation and refinement of key programmatic elements, including assessments, care plans, patient education materials, and protocols. Complies with all OSHA and Safety guidelines patient complaints, unusual incident reports, HIPAA and OSHA incidents. Assists the Director of Population Health Services in evaluating the quality of care in the program through a clinical and value lens and implements quality improvement processes to achieve desired outcomes. Minimum Qualifications: Bachelor of Science degree in Nursing required A current, unencumbered DC Registered Nurse license with current CPR certification required. Primary care experience preferred. Care management and patient education experience preferred. Experience working with patients with substance use disorders and behavioral health concerns preferred. Knowledge of chronic disease processes and health maintenance required. Demonstrated cultural competence in communicating with low-income populations required. Ability to work with computers and electronic health records required. Strong verbal and written communication skills required We offer great benefits including: Medical Plans through CareFirst BlueCross Blue Shield; Dental Plans through CareFirst BlueCross Blue Shield; 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; Transportation pre-tax payroll deduction for metro; Generous paid vacation leave, sick leave and holidays; Tuition Reimbursement for graduate studies; And much more! About Us: Community of Hope is a rapidly growing, innovative, and mission driven nonprofit. For nearly 40 years, we have provided health-care, housing, and supportive services for low-income, underserved, and homeless people in Washington DC. We currently operate a variety of housing programs and three community health centers, which offer medical, dental, behavioral health, and birth services. Through providing these programs and supportive services, we continue our mission of helping and enabling people achieve good health, a stable home, family sustaining income, and hope. Community of Hope was selected as one of the Washington Post’s 150 Top Workplaces in 2014, 2016, 2017, 2018, and 2020. We received the 2012 Washington Post Award for Excellence in Nonprofit Management and the 2014 Leadership Greater Washington Innovative Community Partnership Award. We were also recognized in 2012 by the National Committee for Quality Assurance as a level 3 Patient-Centered Medical Home.