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.

• We celebrate people’s strengths and acknowledge the impact of trauma on people’s 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.

• 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 patient’s 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 patient’s 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.

• Bachelor’s 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 driver’s 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…