Title: Ryan White Medical Case Manager

FLSA Category: Exempt

Reports To: Manager, Case Management

Date Issued: October 2016, Revised June 2023

Job Summary:

Coordinates healthcare needs, referrals, follow-up and resources for Ryan White grant specific,

chronic disease and GBMS patients as required. Targeted patients may include those in special

population groups identified as at risk for poor health outcomes or any patient requiring

assistance

Essential Functions:

1. Responsible for providing (and leading more junior staff to provide) patient-centered services

that link with comprehensive medical care including initial and on-going client assessment

and monitoring.

2. Provides on-going support and crisis intervention, and advocates for patient when necessary.

3. Responsible for maintaining register of patients enrolled in special program services.

4. Works and communicates with providers to identify new patients for all Ryan White programs.

5. Assists patients to access ancillary services and community referrals, including mental

health, substance abuse, dental care, nutritional counseling, pharmacy assistance, specialty

and diagnostic care, durable medical equipment and legal services, and any additional

services/referrals based on patient needs.

6. Maintains ongoing collaboration with the medical provider and health care team to maximize

treatment adherence, and to resolve issues compromising compliance and patient’s wellbeing.

7. Reviews schedules daily prior to appointments and cross-checks with active patient rosters to

determine any patient’s needs that can be addressed while in the clinic. This includes

communication with the provider the day before and/or the morning of the patient’s

appointment.

8. Maintains ongoing communication with providers regarding patient’s status and follow-up

outcomes from prior provider requests.

9. Acts as a resource for providers and staff in determining services available and funding

available for special patient populations (including grant funded programs).

10. Works with management and executive team or to maintain and implement tracking system

for authorizations and referrals.

11. Documents and records patient data (as required for various Ryan White grant programs) and

reports the outcome of compliance monthly to management and executive team as requested.

12. Provides follow up services as requested by the provider and/or as indicated by the needs of

the patient.

13. Utilizes the Patient Electronic Record data base to track patient treatments, laboratory results

and self management goals.

14. Proficient in the use of the eCW system to schedule appointments and provide referrals.

15. Assists eligible patients in enrolling in patient assistance programs such as, MCHIP, SSI,

pharmacy assistance, TAP, MADAP, and other programs as eligible.

16. Ability to utilize and be available to perform Telehealth visits dependent upon patients’

needs

Nonessential Functions:

17. Participates in various committees/meetings in the community, as it relates to case

management or relevant programs to ensure agency participation.

18. Participates in outreach or delegates outreach when appropriate.

19. Participates in team/staff meetings; attends in-service meetings and applicable workshops.

20. Performs other duties as assigned by supervisor.

Core Values:

Quality, Respect, Teamwork, Equity, Integrity, Passion

Supervisory Responsibility-None

Managerial Responsibilities- None

Minimum Qualifications

1. Bachelor’s degree in nursing, social work or related field.

2. Licensure as a Physician, Nurse or Social Worker in the jurisdiction(s) in which services are

rendered, and

3. Current Registered Nursing License in the State of Maryland or Current Social WorkClinical License in the State of Maryland.

4. Board certification or eligibility in Social Work-Clinical or Nursing.

5. Insurability (malpractice)

6. Three (3) years of specified work experience.

7. A minimum of one (1) year experience working with HIV case management or relevant

adult/pediatric community health work-clinical or hospital based.

Substitutions: None

Collaboration - Engages others by gathering multiple views and being open to diverse

perspectives, focusing on a shared purpose that puts the organization overall success first.

Work Environment

This job operates in an outpatient office environment. This role is frequently exposed to {fumes

or airborne particles, moving mechanical parts and vibration}, and high stress situations or

events.

Physical and Mental Demands

1. Ability to cope with stress.

2. The person in this position needs to occasionally move about inside the office

3. Constantly operates a computer and other office productivity machinery, such as a calculator,

copy machine and computer printer.

4. The person in this position frequently communicates with patients and/or employees. Must

be able to summarize and exchange accurate information.

5. Must be able to lift or catch patient weighing more than 50 pounds in the event of

emergency.

6. Performs with frequent interruption or distractions.

7. Adjust priorities quickly as circumstances dictate.

8. Ability to interact appropriately with colleagues for different purposes in different context.

9. Ability to perceive the nature of sound.

10. Expressing or exchanging information by means of the spoken word, or to convey detailed

spoken instructions accurately, loudly or quickly.

11. Ability to judge distances and spatial relationships to perceive objects where and as they

actually are.

12. Cognitive ability to analyze, count, summarize and synthesize information from multiple

sources.

13. Ability to recognize social or professional behavioral cues.

Compliance: This position requires compliance with Greater Baden Medical Services (Health Center’s)

compliance standards, including its Standard of Conduct, Compliance Program, and policies and

procedures. Such compliance will be an element considered as part of the Ryan White Medical

Case Manager’s regular performance evaluation.

Language Skills: Ability to read and interpret written or verbal documents and instructions. Ability to speak

effectively to patients, employees and/or stakeholders of the organization.

Travel: Must be able to drive between Greater Baden Medical Services, Inc. locations; and eternal

locations necessary to maintain programmatic collaboration and compliance.