Reporting to the Case Manager Supervisor and/or their designee, the Medical Case Manager is responsible for providing daily care coordination, case management, and direct patient care. This position works with HIV/AIDS and Hepatitis-C infected individuals. The incumbent will work as part of an interdisciplinary care team including, but not limited to, coordinating patient services such non- medical case management, mental health and substance abuse treatment and integration of primary medical and specialty care. This position provides health education for patients with an emphasis on medication adherence and treatment compliance. This position works as part of the Integrated Behavioral Health Case Management team.
Contacts and interactions vary and may involve multiple constituencies such as direct interaction with THC’s executive management, community organizers, the general public, THC’s patients, physicians, colleagues, assigned staff, vendors, contractors and consultants for the purpose of providing and exchanging information.
Example of Essential Job Functions
· Manages a caseload of patients
· Ensures all intake assessments are completed
· Ability to assess clients for needs related to treatment education, risk reduction and prevention.
· Responsible for All new patients and employees are properly oriented to the unit (i.e. understand rules, policies, procedures, sign consent/release of information forms)
· Responsible for developing, implementing and evaluating individualized patient care plans
· Establishes long and short term goals for the patient which are S-M-A-R-T(Smart, Measurable, Achievable, Realistic, Timely)
· Educates patients regarding the disease process and medications, methods for improving medication compliance, available community resources and other pertinent information.
· Ensure the patients are linked to care management and staff adhere to appropriate lines of communication regarding the work being done with patients
· Directs and monitors team members in implementing patient’s care plan.
· Maintains extensive knowledge regarding the current standards of HIV/AIDS care and case management processes.
· Ensure quality care is delivered in an efficient and effective manner.
· Ensure customer service standards are continuously demonstrated.
· Engaging patients and their care givers in understanding and setting self-management plans in a culturally and linguistically appropriate manner.
· Facilitates and coordinates services to develop patient-centered, individualized, integrated patient care plans, including self-management and outcomes goals.
· Collaborate with various health care providers across the care continuum to ensure that patients are effectively managed and that health care needs are met.
· Ensure that advance preparations for patients are coordinated for providers and with patients.
· Participates in patient centered interdisciplinary care conferences and meetings as required.
· Responsible for care in collaboration with the patient’s physician, the patient and/or family representative, and other members of the professional staff
· Acts as a liaison between patients, their families and healthcare providers
· Providing clinical expertise for assigned patient population
· Reassessing all treatment plans according to policy and as needed
· Improve patients’ quality of life through collaboration and follow up care
· Facilitate collaboration between community health education resources and the patients
· Assist patients with creating, monitoring and documentation of self-management goals and follow up with patients regarding set goals
· Communicates to other team members regarding the status of patients’ social and mental health needs
· Monitor patients’ use of health center services and the adequateness and effectiveness of the services utilized, including patient flow
· Develops and maintains policies and procedures as required
· Participates in professional development opportunities and attends staff/team meetings as deemed necessary
· Documents in medical record per policy and standards
· Maintains accurate and up-to-date records in a timely manner
· Provides in-service training, and on-the-job training to new staff within the scope of service
· Assist with audits and quality issues
· Provide services in clinic within the scope of services of license as directed by Supervisory staff.
· Facilitates referrals to specialty care and support services
· Follows up on all medical care related referrals and documents all contact and outcome in the medical record.
· Interacts with providers, including specialists, to ensure comprehensive care for the patients
· Disseminates information and educates the provider community and patients regarding the latest treatment protocols in HIV/AIDS management.
· Collaborates with ASOs and other community services in the Eligible Metropolitan Area (EMA), including specialty care providers, as necessary to ensure appropriate access to services and follow-up on the results to such referrals
· Effectively tracks outcomes of care on an individual and aggregate basis regarding the patients
· Monitors patients acuity level in an ongoing fashion to ensure transition to reduced intensity of services when patient is no longer an acuity level that necessitates medical case management.
· Communicates with all team members about changes to level of services
· Maintains information in a confidential manner in compliance with HIPAA and confidentiality policies and procedures.
· Participation in required Ryan White staff meetings
· Clinical coverage for direct patient care when needed
· Performs other duties as assigned within the scope of license.
Minimum Education, Training and Experience Required
The LMHP is a Licensed Mental Health Provider who is licensed as a Licensed Certified Professional Counselor or Licensed Clinical Marriage and Family Therapist (LCPC or LCMFT) A LGSW degree and license or LGPC degree and license. One year of case management required. Ryan White experience preferred.
Internal Number: MCM
About Total Health Care
Our Mission: Total Health Care, Inc. is dedicated to providing Accessible, Affordable Healthcare with Dignity, Respect, and Compassion.Our Vision: The mission of THC is to improve the health and quality of life for all. THC seeks to improve the health status of the greater Baltimore communities through health education, outreach, and preventive health programs that change lifestyles and at-risk behaviors ' regardless of ability to pay. THC's vision is to be the premier community-responsive health care organization in Maryland. This vision is underscored by its commitment to service delivery excellence, prioritization of customer satisfaction, emphasis on prevention and wellness care, involvement in community capacity building, the cultural ability to serve a diverse and high-risk, vulnerable population.In 2014 we saw 38,000 unique patients and combined proudly served; over 150,000 visits for the following services:•Primary care•Assistance in filling out applications for housing•Referrals for dental and specialty care•Pharmacy and medical assistance•Substance abuse treatment•Vision services•Employment assistance•Health screenings•Medication monitoring•Community health care outreach