Medical Case Manager

JOB CONTENT

Position Summary:

(Overall purpose of this position)

• Medical Case Management is provided in partnership and collaboration with patients living with HIV, their family/caregiver(s), HIV primary care team (providers, nurse care coordinator, medical assistant, clinical pharmacist), and community social service agencies in a team approach to promote timely access, linkage and retention in HIV primary care to achieve and maintain viral suppression and retention in care and to address identified social needs.

Essential duties and responsibilities which must be performed in order to carry out the position purpose summarized above:

(The following description is a general representation of the key duties and responsibilities of this position. Other duties may be assigned, as required.)

1. Serve as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources.
2. Work with patients living with HIV to determine initial, and on-going, eligibility for Ryan White services.
3. Assess patient’s unmet physical, behavioral health and social needs with cultural and linguistically appropriate intervention.
4. Develop a care plan with the patient, nurse care coordinator and providers which include goals, identification of barriers and action plans.
5. Promote and monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate change through Motivational Interviewing as needed.
6. Increase patients’ ability for self-management and shared decision-making.
7. Work with nurse care coordinator and clinical pharmacist to ensure medication adherence.
8. Connect patients to relevant community resources, with the goal of addressing social determinants of health to enhance patient health and well-being, increasing patient satisfaction, and reduce health care costs.
9. Facilitate patient access to appropriate medical and specialty providers and social service agencies.
10. Educate patient and family/caregiver(s) about relevant community resources and assist them in accessing resources as needed.
11. Monitor follow-up referrals.
12. In a timely fashion, address barriers to patient/family accessing resources.
13. Facilitate and attend meetings between patient, family/caregiver(s), care team, payers, and community resources, as needed.
14. Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.
15. Assist with the identification of “high-risk” patients (the chronically ill and those with special health care needs) and add these to the patient registry (or flag in EHR).
16. Responsible for timely data entry into Ryan White data entry system. Ensures all Ryan White invoices are prepared, and submitted, to financial analyst for monthly submission to Cuyahoga County Board of Health.
17. Attend all training courses/webinars and meetings as scheduled.
18. Provide feedback for the improvement of the Care Coordination Program.

Qualifications:

1. Specific knowledge, training or skills required to perform the duties of this position. Specific concepts, courses, training programs or required certifications:

(To perform this position successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills and abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.)

• Core values consistent with a patient-and family-centered appro