Case Manager - Ryan White

Position Summary: Under supervision (reports to) of the Program Manager, assesses individuals living with HIV/AIDS for problems and needs with a focus on improving health outcomes in the HIV care continuum. Performs Medical Case Management duties including, but not limited to coordination of services and follow-up of medical care. Provides patient education and counseling, advises healthcare providers, and makes necessary referrals for other social services. This job is a grant funded position under the Ryan White Part A program. Duties and Responsibilities: Assist with the promotion of medical home, team-based care by working with internal/external partners to help patients overcome barriers within the healthcare system. Provide initial assessment of service needs, development of a comprehensive, individualized service plan, and continuous client monitoring to assess efficacy of the care plan. Consult and coordinate with health care team members to assess, plan, implement and evaluate client care plans. Facilitates interaction and communication with healthcare and behavioral staff and other providers in order to link patients to the appropriate levels of care. Re-evaluate the care plan with ongoing assessment of client’s needs and personal support systems. Educate clients to help them better understand and manage their health and illnesses. Provides education to patients regarding HIV, opportunistic diseases and HIV related behavioral disorders such as depression and anxiety. Provide Care Coordination for patients with HIV and other uncontrolled chronic conditions, with backup provided by Southside’s Patient Care Coordinator. Coordinate timely access to medically appropriate levels of health and support services partners to help patients overcome barriers within the healthcare system. Act as client advocate in order to coordinate required services or to resolve crisis. Refer clients to community resources that provide access to needed services such as financial assistance, food security, legal aid, housing, job placement, and education. Assist clients in obtaining access to public and private programs for which they may be eligible such as Medicaid, Medicare Part D, ADAP, Patient Assistance Programs, and plans through the health insurance Marketplace/Exchange. Track interventions and outcomes. Prepare and maintain all required treatment records and reports. Measure and report health outcome data to Ryan White Program Manager and Quality Management team. Adhere to standards of case management and appropriate health professional code of ethics. Maintain confidentiality of records relating to client care and treatment. Participates in ongoing training to maintain core proficiencies of the program or service. Receives 2 hours of supervision per month by manager. Performs other duties as assigned. Knowledge, Skills and Abilities: Ability to use mature judgement in patient education/counseling and care coordination. Ability to follow information/directions received and provide information/directions to others. Ability to ensure adherence to all applicable policies and procedures. Sensitivity to needs and concerns of patients. Excellent verbal communication and documentation skills. Knowledgeable about health and social services providers, organizations and services in the local community. Minimum Qualifications: Licensed Master Social Worker Previous experience in medical case management or care coordination. Must abide by NASW Code of Ethics Preferred: Previous experience serving individuals living with HIV/AIDS. Completed certifications in motivational interviewing certification and pre- and post-HIV test counseling OR can obtain certification within first three months of start date. Familiarity with Electronic Health Records, proficiency in Microsoft Excel and Outlook. Typical Physical Demands: Requires normal visual acuity and hearing, manual dexterity and eye-hand coordination sufficient to operate a keyboard, telephone, and other equipment. May require sitting for prolonged periods of time during patient appointments and documentation. Occasionally lifts and carries items weighing up to 10 pounds. Typical Working Conditions: Administrative and medical office environment with potential exposure to communicable diseases, bodily fluids, toxic and others substances common to clinic environment. May involve work under stress in emergency situations or during irregular hours. Southside is committed to providing Equal Employment Opportunity to each employee. Southside will not engage in unlawful discrimination against or harassment of any person employed by or seeking employment on the basis of race, color, religion, sex, sexual orientation, gender identity, ancestry, national origin, place of birth, age, marital status, veteran status, or any other characteristic protected by applicable federal, state or local law.