Lead Care Coordination Specialist

Community of Hope • Washington, DC

1d • $28 - $29 • Onsite

About The Position

Community of Hope is seeking a Lead Care Coordination Specialist to lead the Population Health Care Coordination team while managing the day-to-day effectiveness of the care coordination service delivery. As Lead Care Coordination Specialist, you'll work to directly deliver or effectively connect patients to appropriate wellness resources, public benefit programs, and other needed social services/community resources in a timely and culturally appropriate manner. This is a full-time position based out of our Conway Health and Resource Center in SW, Washington, DC.

Requirements

• High school diploma or GED equivalency.
• At least 2 years of experience in the heath-related field.
• 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.
• Ability to work with computers, including electronic health records.
• Ability to work flexible hours, including evenings and weekends.
• Ability to work from other COH locations and travel between COH sites.

Nice To Haves

• Bachelor’s Degree required.
• BSW or BA in health-related field.
• At least one year of supervisory experience.
• Experience with educating patients with chronic health conditions.
• Experience working with patients experiencing behavioral health and substance use issues .

Responsibilities

• Leads the Population Health Care Coordination team while managing the day-to-day effectiveness of the care coordination service delivery model, which includes the evaluation of program outcomes and individual staff productivity and performance.
• Assists Population Health Nursing Staff in collecting information to complete accurate initial biopsychosocial assessments, including interviewing the patient, and gathering data from eCw and outside data sources.
• Works with Population Health Nursing Staff to assist 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 plan.
• Attempts to complete in person or telephonic monthly follow-up to one-hundred percent of My Health GPS patients. Follow-up includes an assessment of current medical and social needs, documentation of recent health care interactions, and a status update on individualized care plan goals.
• Provides referrals to community resources, including housing, job training programs, support groups, transportation, child care, etc. Tracks whether referrals are completed and successful in resolving patient needs.
• Ensures patients complete primary and specialty care appointments by proactively working to resolve patient-identified barriers, making reminder calls, scheduling appointments, arranging transportation, contacting patients following missed appointments, etc.
• Provides education to patients and caregivers regarding health conditions, medication management, healthy lifestyle and chronic disease self-management in a variety of settings, including the waiting room, educational groups, phone calls, and one-on-one meetings.
• Facilitates patient empowerment and engagement by promoting educated, independent patient choice on all aspects of care, including encouraging patients to ask questions and understand the purpose of prescribed treatment and helping patients develop competency in understanding their personal medical information and health conditions.
• Meets with supervisees regularly and provides ongoing feedback and support, including opportunities for professional development.
• Performs other duties as assigned by supervisor.

Benefits

• 8 x Washington Post 150 Top Workplaces winner.
• 8-hour workdays with paid lunch.
• 3 weeks vacation (additional week after two years), 2 weeks sick leave, + 11.5 paid holidays and one personal floating holiday on an annual basis.
• Annual performance-based raises, up to 5% of your annual pay.
• Tuition reimbursement & loan repayment (NHSC & DCHPLRP), Licensing reimbursement & CEU funding.
• Medical, dental, vision, life & disability insurance + 403(b) retirement.
• Leadership development, internal promotions and career growth opportunities.
• A culture grounded in equity, compassion, and well-being.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED
• Number of Employees: 101-250 employees