RN / Registered Nurse / District of Columbia / Permanent / NURSE CARE MANAGER Job

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 patients 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 incidentsCommunicates 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.