Perinatal Services Case Manager, HONEY - Community of HOPE

• We care for families by providing direct services with a focus on prevention, healing, and wellness.
• We improve lives by building on families’ strengths, honoring their choices, and taking a whole-family, multi-generational approach.
• We lead and advocate for system change to address the effects of historical and current racial inequities on health outcomes and housing opportunities.
• We embrace the diversity of our community, welcome all voices and perspectives, and treat everyone with respect, compassion, and integrity.
• We strive for excellence in all that we do, implement evidence-based practices, measure our outcomes, and use this knowledge to continuously strengthen our work.

• Maintains a case load of about 30 participants who are referred from the perinatal navigators at the Virginia Williams Family Resource Center, providing care coordination services to ensure access to perinatal health and early child health services. 
• Conducts thorough assessment on all prenatal/postpartum clients utilizing OB Authorization form, Healthy Screening tools (HITS, 4P’s, PHQ-9, Edinburgh). Follows up and refers patient appropriately based on risk.
• Attempts to complete in person or telephonic monthly follow up on 100% of clients. Follow up includes an assessment of current social needs, documentation of recent health care interactions and status update on individualized care plans.
• Provides health education to clients in variety of settings, with an emphasis of increasing understanding of healthy pregnancy, self- management of care and the health systems.
• Utilizes non-COH data sources, including CRISP, to coordinate care for high risk clients to ensure providers have access to accurate and complete medical information at the point of care
• Assists clients in setting short- and long-term goals utilizing motivational interviewing strategies. 
• Develops care plans with designated periods with particular emphasis on risk factors, including but not limited to social needs, barriers to care, pregnancy planning, and food insecurity. 
• Available for home and/or hospital visits as determined by the Homeless System Perinatal Services program.  
• Ensures all prenatal and postpartum clients utilize referrals provided through weekly reminder calls. Assists with provider appointments, including but not limited to, following up/rescheduling of missed appointments, and ensuring access to care.
• Assists as a liaison between the client and their families, homeless services provider, clinical staff and other health care professionals.
• Regularly facilitates individual and group centering and on-site health education with clients as needed.
• Works with Enrollment Specialists to ensure that clients are enrolled in medical insurance. Ensures clients are connected to their Managed Care Organizations case management services department. 
• Promotes breastfeeding during interactions with clients.
• Provides breastfeeding support to include assessing latching and feeding process, providing corrective interventions, counseling mothers, understanding and applying knowledge of milk production and other commonly encountered situations.
• Participates and conducts quality management and evaluation activities as requested.
• Manages client information in compliance with HIPAA, HSRA, and other privacy regulations. Ensures that appropriate releases are completed to facilitate information sharing.
• Follows up with clients or health care providers (with client permission) to ensure successful referral and attendance at appointments.
• Attends Maternal and Child Health department meetings at Community of Hope and all-staff meetings.
• Participates in Virginia Williams Resource Center staff huddles (currently every other Friday).
• Participates in HONEY team meetings and is collaborative in building this innovative model.
• Documents any relevant client encounters, including face to face, telephone, and electronic communications, in eCW or Quickbase within 3 business days and other systems per HIPAA and departmental policies and procedures.
• Responds to all urgent telephone encounters and messages within 1 business day and 3 business days for all others. 
• Secures client information and maintains client confidence by completing and safeguarding medical records and keeping client information confidential. 
• Completes other duties as assigned by supervisor.*

• B.A./B.S. or equivalent experience required; B.A./B.S. in social work, education, or related field preferred.
• Experience providing social services, care coordination or health care education required.
• Familiarity with perinatal services and standard of care required.
• Strong organizational skills. Ability to multi-task and problem solve.
• Strong written and verbal communication skills.
• Experience working with under-resource population, including pregnant people, preferred.
• Familiarity with Medical Assistance system and community resources strongly preferred.
• Ability to travel between sites required.
• Willingness and ability to make home visits and hospital visits, work occasional evenings and weekends.
• Proof of required vaccinations is required.  This includes, but may not be limited to, Flu and Covid. COH will consider requests for reasonable accommodations for anyone who cannot be vaccinated for a religious or medical reason, subject to applicable law.

• 8-hour workdays, which include a paid lunch 
• 11.5 paid company holidays, 1 personal floating holiday, 15 days of paid vacation (increases to 20 after 3 years of service), and 12 days of paid sick leave on an annual basis 
• Annual performance-based raises, up to 5% of your annual pay 
• National Health Service Corps (NHSC) and DC Health Professional Loan Repayment Program (DCHPLRP) participants 
• Tuition reimbursement, loan repayment for clinicians, licensing reimbursement, and continuing education unit funds for licensed staff 
• Many opportunities for internal promotions and transfers across the agency as we continue to grow; we average 30+ promotions each year 
• Ongoing internal leadership training for supervisors 
• Diversity, equity, and inclusion training and initiatives for all staff 
• Ongoing well-being activities, culture compact activities, and trauma-informed care initiatives 
• Medical/Dental/Vision Plans through CareFirst BlueCross Blue Shield 
• Life insurance, short-term disability, and long-term disability insurance 
• 403(b) Retirement Plan 
• Flexible Spending Accounts for medical and dependent care reimbursable expenses 
• And much more! 

Community of Hope is a mission-driven, innovative, and rapidly growing nonprofit. For nearly 40 years, we have provided healthcare, housing, and supportive services for low-income, underserved, and homeless people in Washington DC. As a Federally Qualified Health Center, we provide medical, dental, behavioral health, and care coordination services for the whole family at three locations in DC. Community of Hope also has a strong emphasis on maternal and child health, with a midwifery practice and the only free-standing birth center in DC. In 2020, Community of Hope provided about 28,400 medical visits, 7,000 dental visits, and 10,000 behavioral health visits for about 11,000 patients. Community of Hope is also providing community walk-in COVID testing and COVID vaccines. Community of Hope is also one of the largest providers in DC of housing and support services for families experiencing homelessness.  Through providing these programs, we live out our mission to improve health and end family homelessness to make Washington, DC more equitable.