Title: Medical Case Manager, Grant Funded

　　Department: Care Management

　　FLSA Status: Non-Exempt

　　Reports To: Supervisor, Grant Funded Services

　　Direct Reports: None

　　Purpose: Provide case management for People Living with HIV/AIDS (PLWHA) with the specific goals of achieving and maintaining viral load suppression.

　　Key Job Responsibility Areas

　　Patient/Client Intakes

　　Medical/Non-Medical Case Management/Linkage to Care

　　Retention and Adherence

　　Miscellaneous

　　Detail of Key Job Responsibility Areas

　　Patient/Client Intakes

　　Complete an intake with each PLWHA interested in medical case management, in which patient/client specific information, barriers to care and urgent needs are assessed.

　　Work with peers, team members to orient the patients/clients to the organization with a site tour, overview of available resources, and introductions to treatment team, wrap around teams, etc. if applicable.

　　Meet with patients/clients to complete additional intake paperwork, authorizations, consents based upon desired services, etc.

　　Provide patients/clients with linkage to an insurance assister if needed, obtain required documentation from patients/clients and assists with applications for medication assistance or ADAP as needed.

　　Promote patient/client access into internal agency services including, but not limited to: support groups, housing services, food programs, behavioral wellness, substance use treatment, and medical care.

　　Medical/Non-Medical Case Management and Linkage to Care

　　Responsible and accountable for coordinating all aspects of patient/client care as listed on service plan.

　　Provide Medical and Non-Medical case management for enrolled patients/clients with the specific goals of achieving and maintaining viral load suppression.

　　Schedule patient/client for appointments with required staff at Trillium Health, identify available community-based resources and actively manage appropriate referrals, access, engagement, follow-up and coordination of services identified on service plan.

　　Conduct engagement services (including home visits, hospital visits, reminder phone calls, transportation, etc.) to increase the likelihood that patients/clients will attend appointments at Trillium Health and will follow up with patients/clients regarding missed appointments.

　　Conduct assessments, re-assessments, case conferences and service plan development with the patient/client and multidisciplinary team to reduce barriers to retention and adherence.

　　Ensure that all patient/client interactions are documented in the patient/client electronic health record and AIRS within the designated time frame.

　　Retention and Adherence

　　Responsible for contacting and tracking patients/clients who are not virally suppressed and lost to care.

　　Coordinate case conferences/communication to address patient/client needs:

　　Ensures a case conference/communication with the treatment team for all patients/clients who are lost to care.

　　Based on outcomes of the case conferences/communication, links patients/clients to services such as the Treatment Adherence Program, Behavioral Wellness, partner notification, health education, housing, transportation assistance, etc.

　　Miscellaneous

　　Requires the ability and commitment to respect and support inclusiveness and diversity, including but not limited to individuals of different backgrounds, cultures, races, ages, sexual orientations, gender identities or expressions, transgender, experiences, opinions, etc.

　　Requires individual demonstration of commitment to the One Trillium behaviors and business impacts and modeling them in the organization.

　　Responsible for maintaining confidentiality of all patient/client, employee, protected and proprietary information.

　　Accountable for meeting the performance standards of their department and must participate as requested in compliance audits, process improvement and quality improvement plans.

　　Other specific duties as assigned.

　　Routine and appropriate documentation in the electronic health record of patient/client barriers to care, progress, care plans, changes and notes to ensure Trillium can adequately report in the Ryan White Services Report.

　　Qualifications

　　Associates Degree, B.A. or B.S. preferred, with 2 years of experience working in the field of HIV/AIDS, behavioral health, substance abuse, health education, or other chronic illnesses. Familiarity with regional HIV primary care, mental health, substance abuse and other services and resources. Possess an understanding of community level work and the importance of collaborating and coordinating with other organizations. Effective communication and documentation skills. Cultural and linguistic competence for the target population. Requires the ability and commitment to respect and support inclusiveness and diversity including but not limited to individuals of different backgrounds, cultures, races, ages, sexual orientations, gender identities or expressions, experiences, opinions, etc. Must have a reliable vehicle, a valid NYS driver’s license, and proof of required automobile insurance.

　　Physical Requirements

　　While performing the duties of this job the employee is required to stand, sit, walk. Occasionally the employee must stoop, bend and lift or move up to 25 lbs. Must be able to operate a motor vehicle.

　　In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.