Case Manager HIV

Department/Unit:

HBD - Aids Program

Work Shift:

Day (United States of America)

Salary Range:

$65,102.17 - $100,908.37

JOB DESCRIPTION

POSITION TITLE:   HIV Case Manager: RAP Specialist

DEPARTMENT/DIVISION:  Medicine/HIV

REPORTS TO:   Manager of Client Services

EDUCATION/EXPERIENCE:  Bachelor’s degree in psychology, sociology, social work or related field required. Three to five years documented experience in the provision of case management services to medically compromised patient population, familiarity with community resources and ability to work in a fast-paced, interdisciplinary team setting strongly preferred.

           

RESPONSIBILITIES:

The RAP specialist (RS) works closely with newly diagnosed HIV patients and patients demonstrating ongoing viral load (VL)greater than 200 copies/ml.  The RS coordinates with the peer educator, RAP RN, and HIV provider to identify and address barriers to adherence and retention.  The RS helps the patient with goal setting, self-management and skill development.  Under the supervision and guidance of the manager of client services, the RS provides the following essential duties:

• Facilitates linkage to HIV care within three days of HIV diagnosis (rapid treatment)
• Completes the intake, initial needs assessment, initial service plan at the initial HIV medical visit.  Assures patient receives information on partner services, HIV transmission, U=U, PrEP, HIV disclosure, etc, at the initial visit.
• Assures new RAP patients receive an orientation to the program, understand RAP expectations, and agree to participate.  Documents these activities and patient’s agreement to participate in the program
•  Assures timely follow up of patients initiating new antiretroviral therapy to assess for barriers
• Completes reassessments and service plan updates with the patient at least every 90 days.  Assures service plans provide detailed action steps with corresponding target dates and responsible party
• Facilitates RAP monthly case conference meetings, assuring each RAP patient has a case conference within 30 days of enrollment and at least every 90 days thereafter.  Ideally case conferences are coordinated with reassessments.  Completes formal case conference documentation
• Provides retention interventions
• Serves as primary liaison to care teams outside of the immediate RAP program
• Refers to and coordinates with community support service providers and behavioral health providers on behalf of the RAP patient.  Monthly contact with community case managers. 
• Coordinates services to address medical care needs, as indicated
• Monitors HIV appointment scheduling and attendance, and reengages with patients who missed appointments
• Documents all patient interactions and care coordination efforts in the AMC electronic health record (EHR) and documents all services in AIRS promptly upon provision.   
• Utilizes motivational interviewing in work with patients, applying the transtheoretical model for change, to assist patients with goalsetting, self-management, and other aspects of behavioral change
• Monitors patient status on elements such as STI screens, housing stability, household income, viral load, and risk behaviors, as required by funder
• Provides other client level information to data staff in accordance with grant requirements
• Facilitates crisis intervention as needed
• Communicates frequently with RAP team and supervisor regarding patient progress and needs
• Reviews caseload for patient’s meeting closure criteria and communicates this to supervisor.   Coordinates with supervisor to assure closure note is entered to EHR and closure service is entered to AIRS
• Stays current on RAP guidelines, data entry procedures, and RAP work plan expectations, especially as they relate to the RS position
• Understands Ryan White eligibility expectations, completes initial eligibility form at firs t visit and every 6 months
• Maintains confidentiality in accordance with HIPAA and NYS HIV Confidentiality Law
• Participates in annual mandatory education and performance evaluations
• Complies with the Division of HIV Medicine and AMC center-wide regulations, policies, and procedures
• Participates in HIV quality improvement activities

Additional Responsibilities

• Develops collaborative relationships with HIV testing agencies to facilitate rapid treatment of their newly diagnosed clients as well as retention in care
• Reviews HIV program VL reports to identify potential RAP patients
• Provides occasional cross co