PRIMARY FUNCTIONS: The Part-Time (2 days per week/40% FTE) Ryan White Nurse Case Manager is one of the nurse case managers for Neighborhood Health’s Ryan White patients. Serves as one of the primary clinical points of contact for new patients, coordinates medical care for new and existing patients, and acts as a clinical liaison between the Ryan White physician, the Ryan White program team, and referring medical providers. Provides direct medical case management services to patients who are medically complex, patients reengaging in care, and patients who are noncompliant with significant clinical consequences.

DUTIES/ RESPONSIBILITIES: (Essential Functions: Duties and responsibilities noted with bullets are considered to be the essential functions of the job).

• Acts as first point of clinical contact with new patients for patients who were previously lost to care who are reengaging in care, for patients whose viral load is high, and for patients co-infected with Hepatitis C.
• Performs nursing assessment on patients and documents in electronic medical record.
• Conducts MCM and Mental Health assessments, assigns acuity level and develops Individual Service Plans for new patients: regularly re-assesses on-going patients, as required by standards.
• From physician standing orders, ensures that screening labs are placed and patient follows through in getting labs completed.
• Serves as liaison to Ryan White physician – provides physician with initial assessment notes, highlighting key assessment findings from nursing assessment, reviews incoming medical records and assigns them to physician – highlighting any items that are remarkable or require follow-up.
• Serves as a clinical resource on the Ryan White program and HIV care for medical providers at Neighborhood Health.
• Communicates with referring providers, both within Neighborhood Health and outside of the organization.
• Responsible for timely linkage to clinical care for newly diagnosed Neighborhood Health HIV positive patients, coordinating medical; appointment with HIV physician and communicating with primary care referring physician to smooth transition into care for patient. Responsible for reporting of linkage to care quality metric to Medical Director.
• Acts as one of the primary nurse case managers for HIV care for all Ryan White patients, reviewing laboratory and clinical information, coordinating referrals outside providers, following patients who have been hospitalized and/or treated in emergency room and relaying information to Ryan White medical providers.
• Provides clinical guidance to non-licensed RW personnel and regularly reviews chart to assess quality of care and documentation.
• Provides clinical nursing case navigation for non-HIV clinical problems (i.e., diabetes, hypertension, asthma) in Ryan White patients.
• Re-assigns and hands off patients who no longer need intensive nursing case management to other members of Ryan White case management team.
• Assists with Quality Assurance activities associated with the clinical quality markers required by the Ryan White Program Grant, including the development and implementation of necessary clinical forms and the review of medical charts. Participates in all Ryan White annual Quality Improvement Projects.
• Maintains up-to-date knowledge of HIV standards of care on a continuing basis and disseminates the knowledge to other members of the team on a timely basis.
• Refers patients to internal and external resources for care, such as oral health services, mental health services and specialty services. Assists patients in efficiently navigating the health care system.
• Undertakes patient education, on both HIV- related manifestations, as well as on typical chronic or comorbid conditions, such as diabetes (e.g, insulin and nutrition counseling) or hypertension, etc.
• Ensures patients receive the recommended screenings for maintaining good health status, such as cervical, colon and breast cancer screenings, and follows up with patients who test positive and need referrals for additional diagnosis and/or treatment. Closes referral loop on patients who have abnormal findings requiring referral.
• Monitors outside requests for patient information while maintaining strict HIPAA requirements.
• Accurately tracks and documents activities and interventions.
• Tallies and enters data into Excel, CAREWare and eCW/electronic medical record 
• Submits required monthly narrative and data reports for contract monitor in timely fashion 
• Maintains logs/binders of data and participates in any internal and external audits

OTHER DUTIES:

• Attends regular Ryan White staff meetings and other local/regional meetings as needed.

• Performs duties and assignments within established time frames; meets quality and quantity performance measures for the position; demonstrates a level of quality, efficiency, and accuracy in the performance to ensure the highest standards of excellence

• Maintains patient confidentiality at all times by controlling the information being disclosed to authorized individuals and ensuring compliance with all HIPAA standards. 

QUALIFICATION/EDUCATION and/or EXPERIENCE REQUIREMENTS: 

• An RN licensure in the state of Virginia or compact state and 2 years of Case Management experience 
• Excellent interpersonal communication skills and the ability to work effectively with a diverse work force and client base
• Strong critical thinking and analytical skills.
• Experience with information technology, electronic health records, medical records, culturally diverse populations and care of underserved populations
• Experience with database maintenance and reporting
• Motivated by change dynamics; high-level ability to manage change
• Must be able to juggle multiple demands
• Able to evaluate implementation of program guidelines on a continuing basis, plan for and implement change in an organized and efficient way
• Knowledge of local health care environment and capacity to form partnerships with other like institutions.
• Fluency in Spanish a plus but not required
• Demonstrates a commitment to the mission of Neighborhood Health