Ryan White Medical Case Manager

Description

Medical Case Management includes a range of client-centered services that link clients with medical care, psychosocial and other services. The coordination and follow-up of medical treatments is a component of medical case management, and requires collaboration and coordination between the medical provider and case manager. These services ensure timely and coordinated access to medically appropriate levels of health and support services and continuity of care, through ongoing assessment of the client’s and other key family members’ needs and personal support systems. Medical Case Management includes the provision of treatment adherence counseling to ensure readiness for, and adherence to, complex HIV/AIDS treatments. This position includes client-specific advocacy and/or review of utilization of services, including face-to-face, phone contact and any other forms of communication. It also includes the provision of advice and assistance in obtaining medical, social, community, legal, financial and other needed services. It utilizes a proactive case management model intended to serve persons living with HIV/AIDS with multiple complex psychosocial and/or health related needs, their families and support systems. The model is designed to service individuals who may require and who agree to an intensive level of case management service provision. 

DUTIES & ESSENTIAL JOB FUNCTIONS 

• Demonstrate professional interdisciplinary skills and provides comprehensive Medical Case Management services to clients (including treatment adherence counseling) 
• Perform initial intake assessment and orientation for new HIV/AIDS clients to the program and regularly scheduled follow-up assessments 
• Develop and implement comprehensive, individualized service plans 
• Follow up with assigned clients to provide support, monitor progress on service plan and provide access to available resources 
• Perform client benefits eligibility screening and assists clients with enrollment in appropriate programs 
• Maintain client confidentiality per WCGME policy, HIPAA standards and Act 148 
• Serve as client advocate. Defend and preserve the rights of patients pertaining to all aspects of their care, knowledge and privacy 
• Client home-visits may from time to time be necessary to accomplish service plan 
• Act as a liaison/communication link between the HIV interdisciplinary team and staff of substance abuse agencies, correctional institutions, specialty offices, visiting nurse associations and local HIV/AIDS service organizations for continuity of effective client and family care 
• Process client assistance requests 
• Work with the interdisciplinary team to identify unmet needs that may impact adherence (homelessness, substance abuse, psychiatric illness, acute medical problems, lack of or inadequate health care benefits, etc.) and assists team in prioritizing those needs 
• Participate in interdisciplinary meetings as scheduled 
• Work with providers (MD/NP) in supporting adherence education to all patients on HAART 
• Develop tools and educational materials for patients, families and significant others 
• Participate in HIV team quality management projects and be able to identify areas of concern for future quality management projects; serve as project leader when appropriate 
• Assist the providers in developing measurable short and long-term goals, which are client centered and derived from the medical diagnosis. Involves the client and family in goal setting and individual plan of care 
• Assist HIV program in data collection and fulfilling grant requirements. Perform data entry as required by grants
• Maintain client computer-based (CAREWare and Electronic Medical Records) and hard-copy client records and provides other documentation as required in a timely manner 
• Maintains client computer-based (CAREWare and Electronic Medical Records) and hard-copy client records and provides other documentation as required in a timely manner
• Responsible for collection of clinical data needed for HRSA and other funding source reports, as identified by the Program Director. Collaborates with the interdisciplinary team in the development of policies, procedures, and record keeping forms and other data gathering forms necessary for the program 
• Maintain an information/referral list of available community services 
• Is knowledgeable of accessible resources, entitlement processes and program taxonomies 
• Attend conferences, meetings and trainings specific to HIV/AIDS to maintain a high level of clinical and prevention/public health knowledge 
• Demonstrate flexibility when responding to change Assume accountability for all actions
• Demonstrate leadership and professionalism to other staff 
• Perform other duties as assigned 

Requirements

• Bachelor’s degree (minimum) required, in social work, psychology, sociology, counseling or other related field. LSW a plus. 
• CCHW certification required within 90 days on hire. 
• 5 years’ experience in social/human service delivery 
• Have a working knowledge of HIV/AIDS 
• Have knowledge of, and contact with, health care entities, social service agencies and public entitlement programs in immediate and surrounding communities 
• Have knowledge of service costs and budgetary parameters and be fiscally responsible in carrying out all case management functions and activities 
• Ability to work with diverse populations and with critical and emergency situations 
• Sensitivity to cultural and economic differences 
• Understanding of medical and psychosocial issues related to HIV disease and conditions specifically related to HIV 

PACE Card Metrics 

• 283 RW case management units per month: 1698 >= Y 
• 70% of clients up to date with reassessments per month: 6/6 = Y 
• 70% of clients up to date with recertification per month: 6/6 = Y 
• Accurately document all case notes and services in Careware by the third business day of the month: 6/6 = Y 
• Attend 1 training per year: 1/1 = Y 

 *COVID-19 vaccination required*