SUMMARY:

Client Engagement and Follow-up:

• Provide an overview of case management and/or HIPCSA services including the role and responsibility of the case manager and the client, the agency’s grievance procedures and the Case Management Agreement.

• Completion of the comprehensive assessment, within 30 days of the initial screening, to determine the client’s strengths, resources, needs and problems.

• Work with client to develop a patient-centered care plan which includes realistic, measurable, and mutually acceptable goals that are based on the results of the assessment.

• Identify action steps needed to achieve each goal, including target dates for accomplishment of the stated goals.

• Identify referrals made to other providers/services in connection with action steps.

• Obtain client and case manager’s signature on patient-centered care plan.

• Copy plan and give to client and file original in client’s file.

• Assist client with accessing needed pharmaceutical coverage or applying for insurance coverage to ensure continuity of medical care.

• Consistent contact with client to assess the efficacy of the service plan and stability in housing as well as access to supportive services.
• Ensure client achieves viral suppression within one year of program intake through active and consistent treatment adherence counseling.
• Maintain ongoing contact with referral sources and follow up to ensure implementation.
• Coordinate services required to ensure the implementation of the service plan.
• Track receipt of referrals for all persons supported.
• Provision of treatment adherence counseling to ensure readiness for, and adherence to, complex HIV/AIDS treatments.
• Make appropriate referrals for Friends For All services for all the people supported.
• At least monthly contact with clients to discuss medication and medical appointment adherence.
• Work with clients to reduce deficits in one or more of the following barriers clients may be experiencing: addiction/substance use, mental health disorders, and/or homelessness.
• This position may require fieldwork including visiting client-members’ homes, hospitals, nursing homes, other organizations, etc.

Community Engagement:

• Become a Healthcare Marketplace Certified Applications Counselor to assist clients in selecting a Marketplace health plan, if needed.
• Become SOAR certified within six months to assist clients in applying for Social Security benefits.
• Be trained on the VI-SPDAT to assist clients who are experiencing homelessness be placed on the By Name List.
• Maintain ongoing contact with referral sources and follow up to ensure implementation.

Data Entry:

• Document client enrollment in Ryan White Eligibility System (RWES).
• Document client enrollment in Ryan White Integrated State Eligibility (RWISE) system.
• Provide accurate, complete, and timely data entry and reporting of all relevant program and consumer data into Apricot, CAREWare, HMIS, RWISE, RWES, Evaluweb and/or other reporting systems as requested by supervisor.
• Ensure client assessment data is entered into Apricot.

Case Notes and Documentation:

• Document client specific activities in written notes.
• Establish Ryan White/HIPSCA eligibility and provide certification/recertification for consumers if eligible.
• Establish client eligibility for health insurance or medical coverage and insurance assistance programs as available.

Chart/File Management:

• Oversee and process all HIPCSA referrals to ensure client enrollment and eligibility.
• Ensure all documentation is collected and processed to complete client application.
• Oversee all benefit card requests and terminations.
• Complete all necessary purchase orders to ensure client financial assistance is granted.
• Track and maintain a copy of client Ryan White card for all clients enrolled in the program.

• Disenroll clients when they become ineligible for the program.

• Recruit clients for 340B pharmacy program.
• Ensure enrolled clients meet program eligibility requirements.
• Process and follow-up on all program referrals.
• Complete and track client enrollment in the program.
• Review refill analysis and ensure clients have received proper medication as listed on medication

Referrals and Case Coordination:

• Attend and participate in Interdisciplinary meetings as scheduled.

• Identify and contact community-based organizations, primary care providers, housing services and other needed providers to establish referral agreements and to coordinate collaborative efforts with clients.

• Complete all documentation to show evidence of the time, date, place and description of each case management service.

• Document progress made towards goals by entering case notes in Apricot client database system.

Continued Contact:

• Face to face interaction with client, as required by level of needed support.

• Complete review of patient-centered care plan minimum biannually; making any changes, addition, or deletions to current services.

• Obtain client signature on patient-centered care plan indicating the agreement for continued contact and case management services.

• Document treatment adherence activities, and harm reduction counseling in client’s file; these include keeping medical appointment, taking prescribed medication, refilling prescription, etc.

• Complete Ryan White eligibility assessment annually, including the development of a new patient-centered care plan.

• Regular and predictable attendance is required
• Return all calls, emails and text in a timely manner.
• Participate in weekly or biweekly coaching sessions with supervisor
• Complete Performance Reviews and SMART GOALS
• Participate in All Staff Meetings and In-Service Days

• May need to travel in personal vehicle to meet staff, clients, or community partners at FFA locations or at other locations to meet the needs of the position

- or -

• A Bachelor level degree in Social Work with equivalent to two years full time professional case management in a public service agency (an appropriately supervised BSW internship may count as one year’s experience)
• Experience working with persons with HIV/AIDS preferred.
• Good strategic/critical thinker, self-starter, goal-oriented
• Excellent verbal and written communications.
Ability to operate with purpose, urgency and accuracy in a fast-paced, deadline-driven environment
• - with particular attention to detail and organization
• Ability to work with a diverse client population
• Strong relationship-builder both with team and clients (internal and external)

• Ability to follow verbal and written instructions.
• Proficient with Microsoft Office Suite or related software
• Ability to define problems, collect data, establish facts, and draw valid conclusions
• Maintain confidential information and adhere to all Friends For All policies and procedures regarding sharing of financial information and Protected Health Information (PHI).

• Must have a valid State Driver’s License, provide proof of automobile insurance coverage to employer at all times and have an automobile to be used daily.

We are a mission driven organization made up of people committed to cultivating growth and learning. We believe in providing care for all our clients while providing a welcoming, balanced environment for all our employees. By joining our team, you are joining a group of community-focused professionals who connect people with care.

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.

• Must be sensitive to the culturally and racially diverse nature of clients, patients, employees, and visitors.
• Must be able to interact with everyone in a friendly, helpful manner.
• Embodies FFA Values:
  • Equity and Acceptance
  • Trailblazing, Creative and Fearless
  • Joy and Fun
  • Collaboration and Teamwork
  • Service
  • Awareness

• Requires ability to speak audibly and listen actively.
• Requires ability to use computers, telephones and other office equipment.
• Requires ability to sit for extended periods.
• May require occasional bending and lifting up to 25 pounds.
• May require periodic local travel.

Friends For All is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected Veteran status, age, or any other characteristic protected by law.