Medical Case Manager

About the role

The Medical Case Manager (MCM) will provide medical case management services to eligible adult clinic patients at Positive Impact Health Centers, following applicable funding guidelines and best practice care models. The MCM will function as an integral member of an interdisciplinary team which may include the following: medical provider, behavioral health clinician, medication access specialist, clinical pharmacist, and supportive services staff (Community Health Worker, Patient Navigator, Retention/Adherence Manager). This position description should not be interpreted as all-inclusive. It is intended to identify the major responsibilities and requirements of this position. The incumbent may be requested to perform job-related responsibilities and tasks other than those stated in this position description.

Responsibilities

• Learn and remain current on practice issues related to HIV/AIDS, related medical diagnoses, and medical case management.
• Provide medical case management services to identified patients of the clinic program, following medical case management guidelines established by HRSA/Ryan White and the Metropolitan Atlanta HIV Health Services Planning Council.
• Complete biopsychosocial assessments with new and returning patients, utilizing required screening tools established by the Metropolitan Atlanta HIV Health Services Planning Council and Ryan White/HRSA.
• Provide medical case management services to an average caseload size of 70 patients: develop a comprehensive Individualized Service Plan (ISP); provide ongoing monitoring of ISP with each patient to assess the efficacy of the plan; coordinate services to meet goals of the service plan.
• Perform periodic re-evaluations and revisions/adaptations of service plans.
• Provide adherence and retention counseling to ensure patients maintain health care.
• Identify gaps in core and supportive services, including care resources, mental health, substance abuse, housing, nutrition, and transportation.
• Coordinate referrals and follow-up for medical and non-medical services.
• Actively participate as part of an interdisciplinary care team to assess patient care needs and coordinate service referrals.
• Assist patients with applications and ongoing eligibility for medication access programs (i.e. ADAP and pharmaceutical assistance programs), as needed to support clinic staff.
• Assist Self-Managed patients with social service questions and related needs.
• Develop network of additional community resources.
• Document patient information, activities, referrals and consultations in a timely and accurate manner, through the use of the agency’s electronic medical record system and related reporting software.