- 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.
- 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.
- 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
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Care Coordination Specialist, My Health GPS - Washington, United States - Community of HOPE
Description
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 youAt 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:
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.
