RAP/Part C Case Manager

Department/Unit:

Medicine - Aids Program

Work Shift:

Day (United States of America)

Salary Range:

$65,102.17 - $100,908.37

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 coverage of other case management functions, as needed
• Other duties as assigned by the manager of client services or designee
• Updates release of information forms, health care proxy, and other pertinent information annually
• Submission of monthly update reports to assist manager of client services with RAP monthly narratives.

COMMUNICATIONS SKILLS:
• Evaluates patient circumstances and communicates with the patient in an objective, nonjudgmental manner
• Addresses interpersonal conflicts in a direct and professional manner
• Responds promptly to email and phone messages; responds to routine inquiries or complaints from patients, regulatory agencies, or members of the community
• Reads and understands medical information
• Knowledge of medical terminology
• Fluency in written