Title: Medical Case Manager, Ryan White Part C\

　　Department: Care Management

　　FLSA Status: Non-Exempt

　　Reports To: Manager, Care Management

　　Direct Reports: None

　　Purpose: Provide case management to patients with the specific goal of maintaining viral load suppression and/or other appropriate health outcomes.

　　Key Job Responsibility Areas

　　Patient Intakes

　　Medical/Non-Medical Case Management/Linkage to Care

　　Retention and Adherence

　　Miscellaneous

　　Detail of Key Job Responsibility Areas

　　Patient Intakes

　　Ensure all HIV-positive patients at Trillium Health have an intake in which personal patient information, barriers to care and urgent needs are assessed.

　　Provide new patients with a site tour, overview of available resources, and introductions to treatment team, wrap around teams, etc. if applicable.

　　Collaborate with local agencies, medical providers, and government programs.

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

　　Provide linkage to an insurance assister if needed and obtains required documentation from patients and assists applications for medication assistance or ADAP as needed.

　　Monitor HIV positive patients following their initial connection with Trillium Health and works to maintain their ongoing and timely engagement in care.

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

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

　　RW-C Case Management and Linkage to Care

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

　　Provide Medical Case Management for HIV+ patients with the specific goals of achieving and maintaining viral load suppression.

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

　　May conduct home visits and hospital visits to meet with patients.

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

　　Ensure that patient progress notes are completed and submitted to supervisor within the designated time frame.

　　Retention and Adherence

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

　　Coordinate case conferences/communication to address patient needs:

　　Ensure a case conference/commination with the treatment team for all patients who are lost to care.

　　Based on outcomes of the case conferences/communication, links patients 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.

　　Employees are accountable for meeting the performance standards of their departments 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 barriers to care, progress, care plans, changes and notes to ensure Trillium can adequately report in the Ryan White Services Report.

　　Qualifications

　　Degree in Health and Human Services, Social Work, or a closely related field and/or 2 years of experience working in the field of HIV/AIDS, behavioral health, substance abuse or other chronic illnesses. Possess an understanding of community level work and the importance of collaborating and coordinating with community based organizations. Computer proficiency is required. Fluency in Spanish and/or ASL preferred. Must have a positive attitude, demonstrate initiative and professionalism. Must be accustomed to diversity. Ability to maintain confidentiality is essential. Must be able to work flexible hours including weekdays, evenings and weekends when needed. 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.