Care Manager - HH Plus Program

Position Summary

The Health Home Plus (HH+) program is designed to provide intensive services to persons living with HIV (PLWH) to stabilize their health and social service needs in the community. The primary function of the Health Home Plus Care Manager (HHPCM) is to guide identified HH+ patients through the healthcare system, assist with access issues, develop relationships with service providers, and track interventions and outcomes.

Duties And Responsibilities

• Provides direct service to a caseload of approximately 15-20 patients.
• Conducts and documents initial comprehensive biopsychosocial assessments of patients’ needs including medical, mental health, substance use and social determinants of health in accordance with Health Home Plus guidelines.
• Assesses, reassesses, and plan of care updates must be conducted face to face in patients’ place of residence.
• Provides crisis intervention and health education services as needed.
• Provides HIV prevention, risk reduction and treatment education.
• Works closely with patient to identify and address barriers to adhering to care.
• Develops individualized patient centered plan of care with documented input and approval from other providers and the patient in compliance with Health Home standards.
• Collaborates with patient and care team to implement plan of care towards achieving goals.
• Coordinates care plan driven services with internal and external service providers through regular care conferencing at the time of reassessment (every 6 months) or whenever there is a significant change in the client’s status.
• Prepares for and facilitates team meetings to delegate plan of care tasks to care team members.
• Maintains timely and effective communication with care team regarding all relevant matters pertaining to patient care.

Education And Experience Required

• Masters or Bachelor’s Degree in Human Services, Education, Social Work or Mental Health is required with at least one (1) year of experience working with target populations defined as individuals with HIV, history of mental illness, homelessness or substance abuse.
• Associates Degree in Health, Human Services, Education, Social Work or Mental Health with at least two (2) years of experience working with target populations defined as individuals with HIV, history of mental illness, homelessness or substance abuse.