Under the direction of the Support Services Director, the Medical Case Manager will work closely with clients living with HIV/AIDS, HCV, and STIs who have multiple psychosocial and/or health related needs. Medical Case Management services is a strength-based approach to service that includes treatment, adherence counseling, coordination and follow-up of medical treatments, client advocacy, and assistance in obtaining housing, financial support, legal services, social support and any other needed service. The goals of Medical Case Management are to ensure that clients with HIV/AIDS, HCV, and STIs have timely access to comprehensive medical care and social services; prevent disease transmission and delay of HIV progression and to promote and support client independence and self-sufficiency. Duties, responsibilities and activities may change at any time with or without notice.
RESPONSIBILITIES / ACCOUNTABILITIES (includes, but not limited to):
• Works in collaboration with the Linkage and Retention Coordinator and Clinical Supervisor to identify clients at intake that need Medical Case Management.
• Collaborate and Consult with Clinical Staff to identify current clients who need medical case management services.
• Works with agencies in the HIV/AIDS service system to engage individuals infected with HIV, increasing the number of clients enrolled in care at Cempa Community Care.
• Provide diagnostic, preventative, restorative, and prosthetic dental care services for clients as required, targeting at least 30 clients served annually.
• Respond within 24 hours to requests for case management services.
• Schedule a screening time within 5 days of the initial request.
• Provide medical case management primary assessment, service planning, monitoring, and follow up activities based on identified need for each client targeting 120 fifteen-minute appointments annually or 10 fifteen-minute appointments for your clients monthly.
• Complete the screening to determine eligibility for medical case management services.
Orientation and Assessment
• Provide an overview of case management services including the role and responsibility of the case manager and the client; the agency’s grievance procedures and the Case Management Agreement.
• Completion of the comprehensive assessment, within 30 days of initial screening, to determine the client’s strengths, resources, needs and barriers.
• Work with clinical staff and client to develop an Individualize Care Plan (ICP) which includes realistic, measurable and mutually acceptable goals that are based on the results of the assessment every six months for each client.
• Identify action steps needs to achieve each goal, including target dates for accomplishment of the stated goals.
• Identify referrals made to other providers/services in connection with action steps.
• Obtain client and case manager’s signatures on ICP.
• Copy plan and give to client and file original in client’s file.
• Educate clients about the importance of participating in adherence of their medical and medication treatment as well as harm reduction, prevention and other HIV, HCV and related sexual transmitted infections (STIs).
Referrals and Case Coordination
• Attend and participate in HIV, HCV and STIs Collaborative Meetings as scheduled.
• Enroll Medical Case Management clients in agency, local, state or federal programs.
• Identify and contact community-based organizations, primary care providers, housing services and other needed providers to establish referral agreements and to coordinate collaborative efforts with clients.
• Complete all documentation to show evidence of the time, date, place and description of each case management service.
• Document progress made toward goals by writing notes in the Data/Assessment/Plan format (DAP).
• Complete all required billing and tracking forms.
• Face to face interaction with client at least every 180 days with a target to visit with 80 clients twice annually for at least 15 minutes each time.
• Complete review of Individualize Care Plan (ICP) every 180 days; making any changes, additions or deletions to current services.
• Obtain clients signature on Individualize Care Plan (ICP) review indicating the agreement for continued contact and case management services.
• Develop intervention plan to re-engage client if face-to-face contact is not maintained and include the intervention in the Individualize Care Plan (ICP).
• Document treatment adherence activities in clients file; these include keeping medical appointments, taking prescribed medication, refilling prescriptions, etc.
• Meet weekly utilization requirement of 24 hours of client contact.
• Provide medical case management reassessment, service planning, monitoring, and follow up activities based on identified need for each client targeting 120 fifteen-minute appointments annually or 10 fifteen-minute appointments for your clients monthly.
• Document the CD4 count, results of viral load test, or prescribed ART medications every 180 days (every 6 months).
• Complete reassessment annually including the development of a new Individualize Care Plan (ICP).
• Participate in and volunteer for intra and interdepartmental activities/events across the agency.
• Communicate regularly with staff about changes, updates, and improvements in service delivery issues or other agency related issues that directly or indirectly impact staff and/or clients.
• Attend agency, local, state, and national meetings, conferences, trainings or workshops as needed or required.
• Adhere to policies and procedures for Cempa Community Care and other off-site programs to ensure quality standards are met.
• Abide by NASW code of ethics, HIPAA and Cempa Community Care Case Management Standards to ensure a prominent level of professionalism is maintained.
• Perform routine self-audits and maintain charts to ensure members information and eligibility documents are current.
• Demonstrate multi-cultural sensitivity and experience or interest in working with underserved communities.
• Able to interact with a variety of people, with a wide understanding of culture, beliefs and economic levels.
• Able to handle confidential and proprietary information appropriately, high level of integrity.
• Ability to prioritize and organize workload, multi-task, adapt quickly to change and deliver under pressure.
• Ability to work in a team-oriented environment.
• Strong customer service skills.
• Bachelor’s Degree in: Social Work, Human Services, Psychology, Sociology, or a closely related field.
• Two+ years’ experience in social services assessment and service delivery.
• Must pass criminal background check, and drug testing
• Knowledge of HIV, HCV, & STI’s preferred.
• Knowledge of mental health and substance use a plus.
• Bilingual Spanish/English a plus.
To learn more about our organization, please visit our website: www.cempa.org
Posted qualifications serve as a guide for candidate review and are not all inclusive. Cempa Community Care reserves the right to deviate from posted credentials in determining what combination of candidate education, experience and skills are best suited to a position. This is a temp to hire position.
Cempa Community Care is an equal provider of services and an equal opportunity employer–Civil Rights Act of 1964 and Americans with Disabilities Act of 1990.