Care Coordination Specialist, My Health GPS

Are you excited about a new opportunity? Do you have a passion for providing high quality medical assistance and patient support? Are you mission-driven to help improve health and eliminate inequities in health outcomes in under-resourced communities in DC? Well, look no further! At Community of Hope, we have worked diligently to improve health and end family homelessness to make Washington, DC, more equitable. We believe everyone in DC should have access to good healthcare, a stable income, and home, and hope! If you are ready to make a positive difference in the community, this position is for you!

At COH, we strive for: Caring for Families. Improving Lives. Leading Change

Our Approach and Values:

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.

Position Summary: The Care Coordination Specialist works to coordinate care for participants in the My Health GPS (MHGPS) program. This role ensures that patients receive timely care and education, social services, referrals, and coordination of specialty care. The Care Coordination Specialist also assists in achieving the goals of the MHGPS program to improve health outcomes, as well as reduce unnecessary emergency room use, hospitalization, and readmission. The position reports to the Director, Nurse Care Management. This is a full-time position at our Marie Reed Health Center in NW, DC. Bilingual in Spanish or Amharic is preferred.

Salary- This position starts at $52k and up based on experience. Indeed provides their own estimated salary calculator and is not affiliated with COH's range.

Highlighted Duties and Responsibilities:

Assists patients in setting short and long term goals with a particular emphasis on social needs, barriers to care, behavioral health support, medication management, and nutrition. Ensures that this information informs the individualized care plans.

Provides patient education regarding healthy living, self-management of care and the health care system in a variety of settings, including the waiting room, educational groups, phone calls, and one to one meetings.

Acts as a liaison between patients and caregivers, providers, clinical staff, specialists and other social service professionals.

Provides referrals to community resources when necessary, including housing, job training programs, support groups, transportation, child care, etc. Ensures patients complete referrals, through reminder calls, assistance in making appointments, transportation assistance, etc.

Communicates regularly with MHGPS patients via face-to-face encounters at least once per month, as well as via the telephone or the patient portal. Meets patients where necessary in order to accomplish this goal.

Facilitates patient empowerment and quality of life by promoting educated, independent patient choice on all aspects of care. Counsels patient and caregivers to better understand health condition, medications, and self-care skills.

Resolves patient needs by utilizing multidisciplinary team strategies. Coordinates with other staff for introduction of the client to support services, ie behavioral health, clinical pharmacist, etc. as needed.

Assists with generating reports which may include analysis of patient populations, efficacy of education, tracking of interventions, UDS reports, etc.

Complies with all OSHA and Safety guidelines

Other duties as needed by supervisor.

Minimum Qualifications:

BSW or BA in related health field required.

At least 2 years of experience in the heath related field preferred.

Experience with educating patients with chronic health conditions preferred.

Bilingual in Spanish or Amharic required.

Commitment to work with underserved populations and ability to work in non-profit environments.

Demonstrates cultural competence in communicating with low-income populations required

Demonstrates 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.

At COH, we understand the toll that the Covid-19 pandemic has taken on the workforce, which is why we prioritize the following well-being and work-life balance-centered benefits:

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!

About Us:

Community of Hope is a mission-driven, innovative, and rapidly growing nonprofit. For over 40 years, we have provided healthcare, housing, and supportive services for under-resourced, underserved and people experiencing homelessness in Washington, DC. 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 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 provides 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 and individuals experiencing homelessness. Through providing these programs, we live out our mission to improve health and end family and individual homelessness to make Washington, DC, more equitable.

Community of Hope cares 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 embrace the diversity of our community, welcome all voices and perspectives, and treat everyone with respect, compassion, and integrity. 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, and 2021 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.

About Community of HOPE:

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.

Full-Time