Case Manager - Ryan White

SOUTHSIDE MEDICAL CENTER•Atlanta, GA

About The Position

The Case Manager works under the supervision of the Program Manager to assess people living with HIV/AIDS, identify problems and needs, and help improve health outcomes across the HIV care continuum. The role provides medical case management, including coordinating services and following up on medical care; educating and counseling patients; advising healthcare providers; and referring clients to social services. This is a grant-funded position under the Ryan White Part A program. The Case Manager supports team-based care by assessing clients’ needs, creating and reviewing individualized service plans, monitoring care-plan effectiveness, and coordinating with healthcare, behavioral health, and community providers. The position also helps clients navigate healthcare systems, access eligible public and private programs, and obtain community resources. It tracks interventions and outcomes, maintains treatment records and reports, and reports health outcome data to the Ryan White Program Manager and Quality Management team. The role requires adherence to case management standards, professional ethics, and confidentiality requirements, as well as ongoing training. The work takes place in an administrative and medical office environment, with possible exposure to communicable diseases, bodily fluids, and other substances common to a clinic. It may involve stressful emergency situations or irregular hours.

Requirements

Licensed Master Social Worker.
Previous experience in medical case management or care coordination.
Must abide by the NASW Code of Ethics.
Ability to use mature judgment in patient education, counseling, and care coordination.
Ability to follow information and directions and provide information and directions to others.
Ability to ensure adherence to applicable policies and procedures.
Sensitivity to patients’ needs and concerns.
Excellent verbal communication and documentation skills.
Knowledge of local community health and social service providers, organizations, and services.

Nice To Haves

Previous experience serving individuals living with HIV/AIDS.
Completed certifications in motivational interviewing and pre- and post-HIV test counseling, or ability to obtain certification within the first three months of the start date.
Familiarity with Electronic Health Records and proficiency in Microsoft Excel and Outlook.

Responsibilities

Promote medical-home and team-based care by working with internal and external partners to help patients overcome healthcare-system barriers.
Assess service needs, develop individualized service plans, monitor clients, and evaluate care plans in coordination with healthcare team members.
Facilitate communication among healthcare and behavioral health staff and other providers to link patients to appropriate care.
Reassess clients’ needs and personal support systems and update care plans accordingly.
Educate clients about managing their health and illnesses, including HIV, opportunistic diseases, and HIV-related behavioral disorders such as depression and anxiety.
Coordinate care for patients with HIV and other uncontrolled chronic conditions, including timely access to appropriate medical and support services.
Advocate for clients to coordinate required services or resolve crises.
Refer clients to community resources for financial assistance, food security, legal aid, housing, job placement, and education.
Help clients access eligible public and private programs, including Medicaid, Medicare Part D, ADAP, Patient Assistance Programs, and health insurance Marketplace/Exchange plans.
Track interventions and outcomes.
Prepare and maintain required treatment records and reports, and report health outcome data to the Ryan White Program Manager and Quality Management team.
Follow case management standards and applicable professional ethics requirements.
Maintain confidentiality of records relating to client care and treatment.
Participate in ongoing training to maintain program or service core proficiencies.
Receive two hours of supervision per month from the manager.
Perform other duties as assigned.