RN / Registered Nurse / District of Columbia / Permanent / NURSE CARE MANAGER Job
Company: Community of Hope
Location: Washington
Posted on: January 15, 2021
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Job Description:
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.
Keywords: Community of Hope, Washington DC , RN / Registered Nurse / District of Columbia / Permanent / NURSE CARE MANAGER Job, Executive , Washington, DC
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