Care Coordinator, Population Health

Community of Hope - Washington, DC (30+ days ago)3.6


Position Summary:
The Care Coordinator works as part of an interdisciplinary care management team that aims to improve health outcomes, as well as reduce unnecessary emergency room use, hospitalizations, and readmissions for a panel of patients with complex health conditions and social contributors to health. The Care Coordinator works closely with patients, nurses, providers, and other care team members to ensure patients receive culturally appropriate, timely, and coordinated care, and have access to social services and resources to address barriers to good health. This position reports to the Director of Population Health Services. This is a full-time position.

Highlighted Duties and Responsibilities:
Works with patients to develop an individualized care plan that includes short and long-term goal setting, with a particular emphasis on social needs, barriers to care, behavioral health support, medication management, and chronic disease self-management.
Provides and tracks referrals to community resources, including housing and job training programs, support groups, legal services, child care, etc.
Reduces gaps and delays in care by ensuring patients complete appointments. Proactively works to resolve patient-identified barriers to care, makes reminder calls, schedules appointments, arranges transportation, contacts patients following missed appointments, etc.
Provides education to patients and caregivers regarding health conditions, medication management, healthy lifestyle and chronic disease self-management.
Facilitates patient empowerment and quality of life by promoting educated, independent patient choice on all aspects of care. Helps patients develop competency in understanding their personal medical information and health conditions.
Ensures that patients receive timely and culturally sensitive support services and interventions and that care is coordinated with patients and across health care providers, settings, conditions, community services, and caregivers.
Communicates regularly with patients via face-to-face encounters, telephone, or patient portal.
Counsels patients on the appropriate utilization of health services in order to avoid unnecessary utilization of emergency rooms and hospitals.
Contributes to programmatic support activities, including reporting, quality improvement initiatives, outreach to eligible patients, and creation of programmatic materials.

Minimum Qualifications:
BSW or BA in related health or social services field preferred.
At least two years of experience in a medical or behavioral health-related field preferred.
Familiarity with community health, common chronic conditions, behavioral health, trauma-informed care, and substance use disorders preferred.
Experience with motivational interviewing and/or providing education in a one-on-one or group setting preferred.
Commitment to work with underserved populations and ability to work in non-profit environments.
Demonstrated cultural competence in communicating with low-income populations.
Demonstrated ability to function effectively in a team.
Willingness to work evenings and Saturday hours.
Ability to work from other COH locations and travel between COH sites.
Ability to work with computers and electronic health records 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 over 35 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 and 2017. 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.

Check out our website here.