Medical Case Manager, Population Health

Washington DC Hybrid $28.84 - $31.25 per hour Washington Post Top Workplace (8x Winner)

Community of Hope is seeking a Medical Case Manager Population Health to provide medical case management services to patients at risk for hospitalization or re-admission due to complex psychosocial and medical needs. You will work closely with the Transitions of Care (TOC) nurse and other Population Health staff to support complex patients who need intensive short-term medical case management or require a higher level of care. This position is located at our Conway Health and Resource Center located in SW Washington DC.

Our Approach and Values:

We celebrate peoples strengths and acknowledge the impact of trauma on peoples lives.

We embrace diversity welcome all voices and treat everyone with respect and compassion.

We lead and advocate for changes to make systems more equitable.

We strive for excellence and value integrity in all that we do.

What Youll Do

• Provides services to patients and families in various settings including COH inpatient facilities and patients homes. Collaborates with hospital staff and outside social service agencies to optimize coordination of social support needed to prevent hospitalization or readmission.
• Identifies COH patients eligible for medical case management services through referrals from the Pop Health Care Management team TOC nurse case conferencing reports in Relevant and from hospital discharge staff.
• Identifies key factors in the patients current social environment that are contributing to their inability to manage complex health conditions and increasing their risk for hospitalization. This may include social determinants of health (SDoH) lack of support poor mobility addictions memory vision or hearing deficits and other factors.
• Develops a case plan with patients and members of their care team that addresses key social factors impacting their ability to manage health conditions and decreases their risk for hospitalization. Uses motivational interviewing to identify patient goals during development of the case plan and during follow-up activities and interventions with the patient and their family/support system.
• Meets regularly with patients on caseload engaging at least 3-5 patients from the panel each day to develop case plans provide appropriate interventions and provide follow-up. Monitors patient progress through the course of treatment re-evaluating and adapting the case plan at required intervals and evaluating outcomes.
• Provides case management interventions to patients on caseload within 7 days of hospital discharge and assesses needs again within 30 days of hospital discharge. Coordinates with TOC nurse nurse navigators and members of the patients care team to support patient engagement in follow-up care.
• Coordinates with all health services and other internal and external service providers regarding clinical care service delivery treatment planning discharge planning and barriers to care. Consults with supervisor on difficult to engage clients.
• Networks with community resources for housing medical adult daycare transportation food employment vision and hearing services safety mobility or memory support for the aging etc. and makes referrals as appropriate.
• Works with outside agencies that provide longer term case management support such as the DC Office on Aging and Community Living to foster a positive working relationship when collaborating on patient care.

Must-Haves

• Bachelors degree in social service or health related field.
• Relevant work experience of at least 1 year in health and/or social service field.
• Strong interpersonal skills able to collaborate and communicate well with others.
• Demonstrated ability to problem-solve think critically and creatively.
• Ability to travel between sites and off-site to inpatient facilities and community meetings.
• Ability to conduct home visits. Valid drivers license and vehicle required as well as proof of auto insurance.
• Ability to work flexible hours including evenings and/or weekends if needed on a case by case basis.
• Proof of vaccinations. COH will consider requests for reasonable accommodations for anyone who cannot be vaccinated for a religious or medical reason subject to applicable law.

Nice-to-Haves

• Experience working with underserved populations required in health-related setting preferred.
• Knowledge of community resources or the ability to become knowledgeable.
• Strong organizational skills and ability to multi-task.

Why Youll Love Working Here! At COH we prioritize the following well-being and work-life balance-centered 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.

About Us

Community of Hope is a mission-driven innovative rapidly growing nonprofit and Federally Qualified Health Center. For over 45 years we have provided health and housing services perinatal care coordination and community support services to make Washington DC more equitable. Community of Hope also strongly emphasizes maternal and child health with midwifery practice and the only free-standing birth center in DC. We are honored to be one of DCs largest providers of housing and homelessness prevention services for families and individuals throughout DC. Through our Family Success Center our WIC nutrition centers and our various partnerships we have reached hundreds and believe that everyone in DC deserves to be healthy housed and hopeful. With the help of our amazing staff we have successfully provided:

• 50000 medical visits
• 6300 dental visits
• 17000 emotional wellness visits
• 1384 families and 220 individuals with housing/homelessness prevention services

Ready to bring hope and health to our DC community Apply today! 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.