Readmissions Reduction Case Manager & Hospital Coordinator

The Readmissions Reduction Case Manager & Hospital Coordinator oversees and administers the Readmissions Reduction Program at MedStar Washington Hospital Center and in the community. This implementation-focused role emphasizes building hospital relationships, coordinating staff, participating in rounds, managing participant intake and operational flow, and providing case management for clients with mental illness and/or substance use disorders. Essential functions are divided into Program Coordination and Case Management duties.

This is a hybrid position, where roughly 50% of work is from home and 50% is on-site at MedStar Washington Hospital Center and in the community in Washington D.C.

What you'll do...

This is a dual role encompassing Hospital Coordinator at Case Manager duties as outlined below:

Hospital Coordinator

• Coordinate with leadership to ensure that all hospital documentation has been received
• Participate in clinical meetings with the medical team at the hospital and provide daily, accurate written documentation regarding clients to case managers
• Assure all necessary patient and hospital data is gathered and recorded
• Collaborate with leadership to assist with assignment of patients to case managers as needed
• Ensure that all intakes are completed in a timely manner prior to discharge
• Participate and coordinate with emergency department and crisis intervention service staff to partner proactively to deter unnecessary admissions
• Work with leadership at the hospital to coordinate programs tasks
• Facilitate and maintain a positive working relationship with hospital staff
• Act as a liaison between hospital medical and social work staff and Mindoula to ensure care coordination services are provided in a supportive and streamlined manner
• Promote and provide education about Mindoula’s case management services
• Advise leadership as necessary to ensure that care coordination is carried out to best practices

Case Manager

• Highly resourceful team-player, with the ability to be extremely effective when working independently
• Proven ability to handle confidential information with discretion, be adaptable to various competing demands, and demonstrate the highest level of customer/client service and response
• Demonstrate ability to achieve high performance goals and meet deadlines in a fast paced environment
• Demonstrate proactive approaches to problem-solving with strong decision-making capability
• Counsel clients with a mental and/or physical disability to assist them with the goal of overcoming dependencies, adjusting to life, and making changes
• Guide clients in the development of skills and/or strategies for managing problems and triggers to increase relapse prevention and reduce risk
• Educate clients about mental or physical illness, abuse, medication, and available community and social resources
• Assess clients for risk, make quick evaluations for risk, and respond, formulating and performing crisis intervention that ensures the safety of clients as necessary
• Formulate interventions with internal and external programs that impact clients and their ability to maintain in the community, being sensitive to clients’ cultural, educational and religious needs 

• Identify triggers and environmental impediments to clients’ progress through interviews and review of records, making reasonable accommodations as necessary
• Prepare and maintain all required records, reports, paperwork, and clients’ diagnostic records, maintaining confidentiality of clients at all times
• Use clear and accurate communication skills (both verbal and written) to facilitate communication with the clients, clients’ family/caregivers, with staff, and treatment team; produce high quality documentation that enables the clients to receive the best treatment possible
• Collaborate with treatment team members to plan or coordinate care, evaluate clients’ medical or physical condition, and to assess clients’ needs
• In a way that does not breach confidentiality, provide appropriate education and information to clients’ families in stressful situations to assist them in understanding, dealing with, or supporting clients
• Evaluate the mental and physical condition of clients via assessments, interviews, review of records, and conferences with other treatment professionals
• Arrange for and monitor psychiatric and medical services, supports, social and vocational opportunities, making treatment referrals as appropriate
• Assist clients in adhering to discharge plan and as necessary, setting up appointments, arranging for transportation to appointments, providing support, or other tasks
• Plan, develop, and implement social services and activities ensuring that all clients’ activities comply with relevant legal and professional standards
• Plan and coordinate discharge from care and treatment facilities as necessary
• Understand local, State, and Federal programs that impact clients’ ability to self sustain in the community and functions in compliance with all related policies, procedures, and regulations
• Use working knowledge of Social Security benefits and public assistance programs to benefit clients
• Assess problem situations to identify causes, gather and process relevant information, generate possible solutions, and make recommendations and/or resolve the problems in a proactive and timely manner.
• Demonstrate compassion and understanding for people dealing with potentially life-threatening situations and be able to assess serious issues, such as the potential for suicide.
• Ability to react immediately, yet calmly, to crisis situations and quickly build rapport with clients.
• Respond to inquiries and/or resolve concerns from clients, caregivers, agencies, or members of the community; inform staff of opportunities to address and resolve problems reported by clients.
• Regularly complete and submit documentation of services provided including accurately completing all case notes in a professional, timely manner
• Effectively liaise and collaborate, both verbally and in writing, with colleagues regarding client’s needs and wellbeing.

What you'll need...

• Bachelor’s Degree in psychology, social work, or other behavioral health discipline from an accredited college or university
• 2-4 years of relevant experience in the behavioral health field providing case management, counseling, and/or crisis intervention
• Knowledge of community resources, social determinants of health, mental health and/or substance use disorders/disabilities, trauma-informed care, recovery/resiliency-oriented services, benefits, and social issues.
• Knowledge of benefits including, but not limited to, SSDI, SSI, Medicaid, Medicare, LTC Medicaid, LTC, STD, LTD, Food Stamps, and Housing Vouchers.
• Excellent computer skills and experience with Google Suite software and Microsoft Office software.
• Must be detail-oriented and able to multitask.
• Excellent oral and written communication skills.
• Must be able to work in a fast-paced environment and have a strong sense of urgency.
• Compliance: Ensures business is operating according to applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violations of applicable rules, and cooperating fully with all organizational investigations and proceedings. Ensures health information management requirements are met.
• Relationship Management: Develops, maintains, and strengthens partnerships with others inside or outside the organization.
• Business Acumen: Understands the extent and importance of business issues, the operation and the industry. Able to implement and achieve goals to ensure a successful future. Conduct all activities with the highest standards of professionalism and confidentiality.
• Communication: Excellent listening, verbal and written communication skills. Clearly and accurately, relaying information to staff, business partners, stakeholders, clients, and clients’ support/treatment team.
• Ability to work cooperatively and effectively with others to set goals, resolve problems, and make decisions that enhance organizational effectiveness.
• Respond positively to supervision and to recommendations for improved performance.