Reports to: Director of Ryan White Services
Position Summary:
Medical Case Management is responsible for the provision of a wide-range of customercentered activities focused on improving health outcomes in support of the HIV prevention and care continuum (Status Neutral). Activities may be prescribed by an interdisciplinary team that includes other specialty care providers. Medical Case Management includes all types of case management encounters (e.g., face-to-face, phone contact, text messaging, and any other forms of communication). Key activities include completing an initial assessment of service needs; developing a comprehensive and individualized care plan; timely and coordinated access to medically appropriate levels of health and support services and continuity of care; continuous customer monitoring to assess the efficacy of the care plan; re-evaluation of the care plan at least every 6 months with adaptations as necessary; ongoing assessment of the customer’s and other key family members’ needs and personal support systems; treatment adherence counseling to ensure readiness for and adherence to complex HIV prevention and treatments; customer-specific advocacy; and review of quality and utilization of services.
Works collaboratively with an interdisciplinary team including prescribers, nurses, case managers, peer recovery/outreach specialists, and non-clinical staff. Responsible for delivering services in accordance with accrediting entities and local, state, and federal laws and regulations governing the practice. The Medical Case Manager may also be responsible for special projects as assigned by the supervisor and in accordance with the needs of the organization. If a Licensed Counselor, the provision of clinical supervision to other staff may be required.
Working Conditions:
1. Sits, stands, bends, lifts, and moves at least 50 pounds intermittently during working hours.
2. Works Monday to Friday, 8:00 AM to 5:00 PM.
Education and Experience:
1. Licensure as a Registered Nurse (RN) or Licensed Social Worker in the District of Columbia (LGSW/LCSW-C or LICSW) is REQUIRED.
2. At least one year of Medical Case Management experience required.
3. A minimum of one (1) year experience working with HIV case management or relevant adult/pediatric, community medical setting such as a clinic or hospital, required.
Improving community health through Holistic Care, Education, and Research. 4. Demonstrate knowledge of medical care coordination and continuity of care.
5. At least one year of experience developing Individualized Care Plans, documenting longand short-term goals and objectives to improve the customer’s health care outcomes.
6. At least one year of experience providing treatment adherence counseling to ensure readiness for or adherence to complex HIV regimens (Preferred, not required).
7. Knowledgeable about community resources.
Specific Requirements:
1. Comfortable serving under-represented and intersectional groups of individuals
including Black, Indigenous, and people of color (BIPOC); LGBQAI+; Transgender and
other gender nonconforming individuals; persons with HIV; individual who are homeless
or housing insecure; and other diverse communities.
2. Commit to working onsite and arriving no later than 8 AM each day.
3. Understand that receiving all recommended vaccines is mandatory at WHI in order to keep everyone we serve and each other safe. This will include Hepatitis B, flu and COVID-19.
4. Hope to stay at WHI for several years in order to learn and grow with us. We are proud of the internal and external training we provide for everyone on our team.
5. Understand that due to our rapid growth some of us work in shared office space.
6. Available to join our team within the next several weeks.
7. Exceptional communication skills, both written and oral, ability to positively influence others with respect and compassion.
8. Must possess the ability to make independent practice decisions when circumstances warrant such action.
9. Must be able to relate information concerning a patient’s situation to the supervisor, when warranted.
10. Strong work ethic built on a foundation of proactivity and teamwork.
11. Ability to navigate ambiguity with the aid of structured problem-solving techniques.
12. Computer proficiency in Microsoft Office.
Clinical Excellence:
1. Manage a caseload of patients with HIV, providing services including referrals and navigation support for medical and non-medical resources, treatment adherence counseling, and crisis intervention.
2. Completes initial case management screenings within required time frames to determine eligibility for services and appropriateness of case management services. The initial screening will include information about receiver support needs, health needs, insurance, housing, legal, social services, employment, peer-support, and other requested services.
3. Work in conjunction with medical care providers (e.g., case conferencing, attending rounds); ensuring all clients are case conferences at medical rounds at least twice per year. Notifies Psychiatrist of changes in patient condition.
4. Implement the medical treatment plan by providing counseling on
medication, appointment, and other treatment adherence issues (e.g., treatment adherence, housing and financial stability, transportation, employment, mental health and substance abuse treatment, family needs, etc.).
Improving community health through Holistic Care, Education, and Research. 5. Collaborates with all treatment providers (internal and external), as applicable and within scope of confidentiality to deliver high quality, coordinated care.
6. Determines appropriate disposition based on assessment findings, needs, strengths and available resources.
7. In collaboration with patients, the treatment team and community provider, creates comprehensive care plans and discharge plans with measurable goals and all activities outlined on the plan to connect patients with ongoing services, if needed. Modifies the care plan as patient conditions or needs change. Short- and long-term goals should focus on attaining, maintaining, and achieving positive health outcomes.
8. Monitor the patient’s follow-through with these services.
9. Provides access to Emergency Assistance (e.g., food vouchers, utility payment assistance, and transportation vouchers) as needed to promote and maintain positive health outcomes.
10. Completes all required documentation in accordance with agency standards including data and reporting requirements (e.g., Retention protocol and reports) charting notes in Electronic Medical Record.
11. Genuine interest and willingness to participate in clinical supervision with team and supervisor, adopting a culture of learning and continuous improvement.
12. Participates in Quality and Performance Improvement initiatives.
13. Adhere to professional boundaries by not transporting clients, not having dual relationships (e.g., serve as payee or accept power of attorney).
14. May be required to participate in onboarding, training activities, community outreach events.
15. If board approved clinical supervisor, may be required to provide clinical supervision.
16. Assist in building strategic relationships with community-based organizations.
17. Other duties as assigned.
The Washington Health Institute was founded with the mission of improving the health of the greater Washington DC Metro community by providing exceptional Primary and Infectious Diseases Specialty care services. The WHI team approaches the unique needs of each patient by providing holistic care, support, and patient education, while participating in innovative research that advances the quality of life for our patients.
We have worked hard to create a culture where everyone is treated with dignity and respect and one in which every employee gets and gives honest feedback so that all of us can grow and develop.
Employment Benefits:
• Competitive salary
• A 403(b) match up to 6%
• Comprehensive health, dental, and vision insurances
• Paid time off
• Professional development
• A culture that respects your unique and special talents
• Free parking
• Metro accessible, Red Line Brookland
