Medical Case Manager

Job Summary

Reporting to the Case Manager Supervisor and/or their designee, the Medical Case Manager is responsible for providing daily care coordination, case management, and direct patient care. This position works with HIV/AIDS and Hepatitis-C infected individuals. The incumbent will work as part of an interdisciplinary care team including, but not limited to, coordinating patient services such non-medical case management, mental health and substance abuse treatment and integration of primary medical and specialty care. This position provides health education for patients with an emphasis on medication adherence and treatment compliance. This position works as part of the Integrated Behavioral Health Case Management team.

Example Of Essential Job Functions

• Manages a caseload of patients
• Ensures all intake assessments are completed
• Absesses clients for needs related to treatment education, risk reduction and prevention
• Develops, implements and evaluates individualized patient care plans
• Establishes long and short term goals for the patient which are S-M-A-R-T(Smart, Measurable, Achievable, Realistic, Timely)
• Edicates patients regarding the disease process and medications, methods for improving medication compliance, available community resources and other pertinent information
• Maintains extensive knowledge regarding the current standards of HIV/AIDS care and case management processes
• Engages patients and their care givers in understanding and setting self-management plans in a culturally and linguistically appropriate manner
• Facilitates and coordinates services to develop patient-centered, individualized, integrated patient care plans, including self-management and outcomes goals
• Collaborates with various health care providers across the care continuum to ensure that patients are effectively managed and that health care needs are met
• Ensures that advance preparations for patients are coordinated for providers and with patients
• Participates in patient centered interdisciplinary care conferences and meetings as required
• Acts as a liaison between patients, their families and healthcare providers
• Provides clinical expertise for assigned patient population
• Reassessing all treatment plans according to policy and as needed
• Improves patients’ quality of life through collaboration and follow up care
• Facilitates collaboration between community health education resources and the patients
• Assists patients with creating, monitoring and documentation of self-management goals and follow up with patients regarding set goals
• Maintains information in a confidential manner in compliance with HIPAA and confidentiality policies and procedures
• Communicates with all team members about changes to level of services
• Participation in required Ryan White staff meetings
• Performs clinical coverage for direct patient care when needed
• Performs other duties as assigned within the scope of license
• Assists with audits and quality issues
• Provides in-service training, and on-the-job training to new staff within the scope of service
• Facilitates referrals to specialty care and support services
• Follows up on all medical care related referrals and documents all contact and outcome in the medical record
• Interacts with providers, including specialists, to ensure comprehensive care for the patients
• Disseminates information and educates the provider community and patients regarding the latest treatment protocols in HIV/AIDS management
• Collaborates with ASOs and other community services in the Eligible Metropolitan Area (EMA), including specialty care providers, as necessary to ensure appropriate access to services and follow-up on the results to such referrals
• Effectively tracks outcomes of care on an individual and aggregate basis regarding the patients
• Maintains information in a confidential manner in compliance with HIPAA and confidentiality policies and procedures

Required Knowledge, Skills And Abilities

• Knowledge of FQHC operations, operating principles, guidelines and bylaws
• Excellent leadership, customer service, organizational and presentation skills as well as the ability to effectively communicate THC’s vision, and motivate others to achieve it organizationally, departmentally, and personally/professionally
• Ability to communicate effectively (verbally and in writing)
• Ability to plan and organize work initiatives to successfully accomplish center/organizational goals and objectives
• Ability to multi-task, prioritize and delegate as appropriate
• Strong analytical, problem solving and interpersonal skills
• Ability to identify, develop and implement short/long-term strategic goals and objectives
• Ability to develop and maintain customer relationships; influence, build credibility and trust
• Ability to think critically as well as apply critical thinking skills
• Ability to: ensure and advocate for quality healthcare and services; and, lead and manage a diverse staff
• Demonstrated knowledge of HIV/AIDS services in Maryland, along with an interest and ability to expand knowledge through training
• Knowledge of the federal 340B program and its requirements
• RN License