JOB SUMMARY/ACCOUNTIBILITY:

The Medical Case Manager works with persons living with HIV helping them manage their HIV medical care needs to facilitate optimal patient outcomes (viral load suppression); promote ongoing long term engagement in medical care, and ensure appropriate service utilization eliminating any gaps in care. The Medical Case Manager works closely with the patient's medical provider to understand what the patient's medical needs are in addition to their psychosocial needs. The Medical Case Manager works closely with the interdisciplinary team moving clients from linkage to care to retention in care through highly coordinated services and efforts. The Medical Case Manager is responsible for patient assessment, service plan development, periodic reassessment of needs, medication adherence counseling, patient education, ongoing monitoring of medical and psychosocial needs, monitoring and evaluation of the patient's progress, and patient discharge from services. 

GENERAL RESPONSIBILITIES:

Demonstrates competency in all facets of clinical interaction including intake, biopsychosocial assessment and reassessment, service planning, progress notes, resource knowledge, referrals, ability to develop rapport with patients, provide health education related to risk reduction and medication adherence. Familiarity with how public and private insurances work and with the Healthcare.gov website. Possess a working knowledge of regulations relating to Medicaid & Ryan White Care Act; familiarity with and ability to navigate the ACA enrollment process and Health.gov website; familiarity with how private and public insurances work.

Implements and evaluates plan of care for each patient. Conducts ongoing review of client's needs and actively links them to appropriate resources. Coordinates with the patient's medical providers to monitor their progress, identifies any needs related to their medical services, assists in facilitating clients linkage and follow through on service/resource obtainment. 

Works as part of interdisciplinary team to achieve optimal health outcomes for patients, such as viral load suppression. Coordinates services and referrals with other members of the team to prevent any gaps in services. Focuses efforts on supporting medical plan of care and keeping patient retained in care. Participates in interdisciplinary team meetings by providing review of client's needs, services, linkage, and progress with goals.

All clinical documentation (intake, assessment, reassessment, service plans, progress notes, releases of information, etc.) are completed fully and within time frames designated. All administration documentation (URS, service activity logs, quarterly grant data statistics submission) are completed fully and within time frames designated.

Educates and builds relationships with other providers of service including physicians, clinics and the public. Maintains awareness of community changes which could impact service delivery. Conducts community outreach and networks with other service providers developing new venues for the program to participate in.

Maintains professional conduct with colleagues and facilitates effective interaction in one on one situations and in meetings. Ability to be a team player. Participates in ongoing trainings to increase skill level as both a presenter and an active audience member. Maintains knowledge of current requirements of regulatory, licensing and accreditation agencies including Standards of Care for HIV/AIDS case management and Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents. 

Staff maintains professional conduct with clients including being on time for visits, returning phone calls, maintaining professional boundaries and educating clients on all MHS services. Understanding of the functions of patient advocacy