Medical case manager

The Medical Case Manager will provide client-centered services and implement the clinical treatment plan, including linking clients into medical, mental, and dental healthcare and other needed services. The coordination and follow-up of medical treatments are key components of medical case management. 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.

Primary Duties and Responsibilities (others may be assigned based upon program needs):

• Provide continuum of care services to persons with HIV/AIDS disease including but not limited to: intake, referral, assessment, coordination, monitoring, reassessment, and follow-up.
• Development of a comprehensive, individualized care plan.
• Continuous client 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 client’s and other key family members’ needs and personal support systems.
• Coordination and linkage of the necessary services that are culturally and linguistically appropriate to implement the plan.
• Client-specific advocacy and/or review of the utilization of services linked to participate in case conferences which include a clinical supervisor as well as the program coordinator as it relates to program goals and objectives which will also entail sustainability of client and ensure client’s progress.
• Maintain up-to-date, accurate and confidential client documentation.
• Enter client data into relevant software programs as determined by funders.
• Maintain communication and coordination with other case managers to ensure qualitative delivery of services based on individual client needs complete reports as needed.
• Coordinate early intervention services and make appropriate client referrals through Care Team Meetings.
• Conduct Psychosocial Groups, as appropriate.
• Develop relationships with other organizations in order to coordinate care to support individuals in attaining appropriate services such as Housing, Mental Health Care, Financial Assistance, Legal Advocacy, Substance Abuse Services, etc.
• Conduct Home Visits, as appropriate.
• Serve on various committees of agency/division as deemed appropriate by management.
• Perform any other department or agency-related duties or special projects as directed by the Division Director; Assistant Director; and/or Program Manager.

Minimum Requirements: Bachelor’s Degree in Health or Human Services, or other related field. Incumbent must demonstrate an ability to work with a culturally diverse population; knowledge of the physical, psychological, social, and economic effects of HIV/AIDS, related issues and health disparities.

Knowledge/Skills/Abilities: Ability to work with individuals from varying socio-economic levels. Demonstrated ability to handle multiple tasks simultaneously. Ability to work independently and prioritize work as needed. Ability to work some weekend and evening hours as requested. Demonstrated proficiency in use of software applications. Excellent writing and organizational skills. Knowledge of local, state and federal social service resources. Must possess personal qualities necessary to relate to clients and staff. Must have strong documentation skills. Able to operate office equipment (e.g. computers, fax, photocopy, postage machines etc.).

Physical Requirements: Primary functions require sufficient physical ability and mobility to work in an office setting; to stand or sit for prolonged periods of time; to occasionally stoop, bend, kneel, crouch, reach, and twist; to lift, carry, push, and/or pull light to moderate amounts of weight; to operate office equipment requiring repetitive hand movement and fine coordination including use of a computer keyboard.

Language Requirements: Ability to read, write and speak English, Spanish and/or Polish (Preferred)