Medical Case Manager

About the role

The Medical Case Manager will coordinate a comprehensive patient care plan under the supervision of the Clinical Psychologist. The role serves as a clinic liaison in the community, working with EIS Workers, Community Health Workers, medical providers, and various agencies to maintain close contact with patients and ensure they remain in HIV care. Each Medical Case Manager is assigned a caseload of clients to provide comprehensive care, including harm reduction, insurance and pharmacy assistance, adherence counseling, care coordination, linkage and reengagement, and referral for core and supportive services.

Responsibilities

• Provide medical case management assessment and re‑assessment according to Ryan White Standards of Care and MCWC Policies and Procedures, entering data in real‑time using CAREWare templates.
• Provide direct patient follow‑up care, attend all assigned meetings, and submit required reports.
• Deliver adherence counseling, service planning, monitoring, follow‑up activities, and treatment adherence counseling based on identified need and acuity.
• Educate patients about HIV/AIDS, STDs, TB, hepatitis, and healthy lifestyles.
• Link and reengage newly identified clients and those who are lost to care.
• Serve as the principal liaison between patients and medical providers, and between Meharry Community Wellness Center and community agencies.
• Monitor clients who are incarcerated, institutionalized, or hospitalized and coordinate their transition and discharge.
• Refer clients to drug treatment and rehabilitation facilities and monitor outcomes.
• Enroll and certify eligible patients into Ryan White and ensure program requirements are met.
• Attend all required meetings, submit periodic reports on time, and perform other related duties as assigned by the Medical Director or Medical Case Manager Supervisor.

Knowledge, Skills, and Abilities

• Ability to work in a multidisciplinary team.
• Ability to foster excellent patient relationships.
• Sensitivity to patient needs and cultural competence.
• Knowledge of the healthcare environment and community outreach.
• Strong interpersonal and communication skills; ability to work effectively with a wide range of constituencies in a diverse community.
• Clerical, word‑processing, and office skills.
• Skill in the use of personal computers and related software applications.
• Skill in electronic medical record systems.
• Records maintenance skills.

Education and Experience

Required: Master’s degree in a health‑related field is preferred; alternatively, a Bachelor’s degree with a minimum of two (2) years of directly related work experience will be considered after special evaluation.

Preferred: Familiarity with patients living with HIV is highly desirable.