Medical Case Manager

PHMC serves as both a direct service provider to individuals, families, and communities across the region and as an intermediary agent — managing large-scale contracts, government and philanthropic partnerships, and multidisciplinary initiatives that require operational sophistication, strategic leadership, and deep mission alignment.

MISSION STATEMENT:

Our mission is to be the premier regional provider of integrated, community-based healthcare by combining evidence-based clinical practices, outstanding patient service, innovative care partnerships, and team-driven excellence, within a healthy fiscal environment.

JOB SUMMARY:

Medical Case Managers are responsible for the coordination of care for clients who are diagnosed with HIV/AIDS at the Care Clinic. The Medical Case Manager reports to the Health Center Administrator.

Age of Patient Population Served: Adult (19-64 yrs.)

Population: All populations

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Maintain a caseload of approximately 50 active clients.
• Act as a liaison between clients and the physician. Advocate as appropriate.
• Complete standardized AACO MCM assessment within 3 days of referral from Client Services Unit.
• Update MCM assessment annually.
• Develop a Medical Care Plan using the AACO standardized Service Care Plan template.
• Provide a treatment adherence and health literacy assessment at intake and during annual Comprehensive Assessment.
• Conduct Treatment Adherence Counseling at least quarterly.
• Identify barriers to medical care and make appropriate referrals to address these issues (i.e., d/a facility, mental health program, care outreach services, etc.).
• MCM will have face-to-face contact with a client at least once every 90 days, with ongoing phone contact as needed.
• Attend medical appointments with each client at least once every 90 days.
• Conduct one home visit for each client annually.
• Maintain and update required paperwork, flow sheets, signatures, and documentation.
• Coordinate with Care Team and Patient Navigators to provide support in locating those lost to care.
• Collaborate with an interdisciplinary team in the evaluation of patient needs and treatment progress.
• Maintain chart documentation (DAP format) to assure timely and accurate communication with team members (documentation in CareWare within 48 hours).
• Assess patient needs and complete referral process to appropriate social services agencies (i.e., drug/alcohol sites, mental health crisis response centers, etc.)
• Enter and update information on the CareWare database for monthly grant reporting requirements (provide 4800 service units annually / 400 units of service per month).
• Attend internal and external trainings and meet training requirements to complete a minimum of 20 hours of continuing education annually in accordance with funding requirements. Submit proof of attendance hours to the AACO Education Coordinator.
• Close cases when services are no longer indicated, or if more than 3 months have passed since the client initiated contact.

PHMC COMPLIANCE RESPONSIBILITIES:

• Understand and adhere to PHMC compliance standards as they appear in the PHMC Code of Conduct, Whistleblowers, and Conflict of Interest Policies.
• Keep abreast of all pertinent federal, state, and PHMC regulations, laws, and policies as they presently exist and as they change or are modified.
• Comply with HIPAA and Confidentiality Policies and Procedures as they apply to the job.
• Comply with Department of Public Health (DPH), The Joint Commission, and other accreditation and regulatory agencies’ standards.
• Adhere to all PHMC Policies and Procedures.
• Know and adhere to Infection Control and Environment of Care Guidelines and Procedures as described in the annual education module.

JOB REQUIREMENTS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills, minimum education, training, licensure, experience, and/or abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Skills:

• Strong interpersonal skills
• Strong organizational skills
• Strong verbal and written communication skills
• Knowledge of community resources preferred
• Bilingual/bi-cultural a plus

Experience: Two years of experience in HIV/AIDS case management services or related work

Education:

Must meet ONE of the following:

• Bachelor’s degree in social work or a related field from an accredited school of social work
• Associate’s degree in social work or a related field, with the intent and desire to obtain a bachelor’s degree in social work or a related field

Physical Demands:

• Able to stand, sit, walk, climb stairs, carry objects, and reach with hands and arms
• Able to kneel, crouch, etc., as needed
• Able to lift to 10 lbs.
• Able to travel by personal automobile or public transportation (reimbursed in accordance with PHMC’s travel reimbursement policy)

WORK ENVIRONMENT:

• Shared work environment
• Moderate noise (e.g., business office with computers and printers, light traffic, etc.)
• The primary work environment is a medical facility, with a degree of exposure to tuberculosis and other airborne diseases. Sound infection control measures are required.

PHMC is an EOE and an E- Verify Employer