Medical Case Manager - Clinical Services Specialist - Temporary

Multnomah County•Portland, OR

2d•$41 - $51

About The Position

Integrated Clinical Services provides quality health services for people who experience barriers to accessing care. The vision of Integrated Clinical Services is to provide services that are integrated and connected to support optimal health, reducing wait times, and optimizing access. The Multnomah County Primary Care Clinics provide comprehensive primary care and behavioral health services to diverse, low-income, uninsured, and underinsured residents of Multnomah County. The clinics provide culturally competent, comprehensive primary care, preventative health and supportive services such as transportation, translation, case management and health education which address the needs of the whole person. Medical case managers play an integral role in the medical team to ensure that the psychosocial needs of clients are met and any barriers to engagement in care and viral suppression are addressed. These needs and barriers include insurance, housing, mental health, substance use, nutrition, basic needs, hospital coordination, crisis intervention, and active referrals to many community partners. Medical case managers are responsible for completing regular assessments and care plans for all clients receiving services. Creates a work culture of respect, trust and understanding for the highly diverse populations the Health Department serves in the office and in the community. Every employee shares the responsibility for promptly bringing to the County's attention conduct that interferes with providing a work environment free of illegal discrimination and harassment.

Requirements

An application/ resume demonstrating you meet minimum qualifications, AND A cover letter addressing: why you are interested in the position, AND how your skills, training and experience meet the required minimum qualifications for this position.
Equivalent to a Master's degree in social work, psychology or counseling
Two (2) years of professional work experience as a counselor, mental health treatment professional, social worker or therapist

Nice To Haves

Training and background at the post-master's level in primary care behavioral health
Ability to effectively respond to crisis situations
Knowledge of or capacity to learn about the local behavioral health treatment system and community resources
Professional demeanor and interpersonal communication skills

Responsibilities

Conducts psychosocial assessments and develops care plans regarding complex and difficult issues of clients with varying stages of HIV/AIDS disease, including persons with multiple diagnoses.
Determines clients’ mental and emotional ability to participate in care and follow up on action plans.
Makes and follows-up on referrals to community partners within the local Ryan White continuum of care as well as non-HIV specific community resources.
Evaluates areas such as alcohol and drug use, HIV prevention, mental health, suicide risk, substance use, social determinants of health, psychosocial issues, cognitive functioning, housing needs, intimate partner violence, and other issues affecting the client’s participation in medical care and HIV medication adherence.
Ensures that clients remain insured and/or enrolled in programs to support access to medication and medical care and assists with completing applications and required paperwork to do so. Works with clients to develop action plans.
Utilizes advanced knowledge and experience working directly with HIV-positive communities in order to ensure culturally competent care is provided to these communities in order to achieve the best health outcomes.
Educates patients on clinic workflows and processes, the medical home model, and team-based care.
Provides services utilizing a strong harm reduction and trauma-informed approach.
Follows up with clients in person and over the phone to track progress and provide assistance and support related to completing action plans.
Assists clients to learn problem solving skills, how to navigate complex systems and to manage emotional and behavioral crises. Includes development of self-care action plans.
Provides comprehensive, team-based medical case management to an assigned panel of complex clients in coordination with the medical provider, nurse, and other clinic staff.
Establishes, coordinates, and monitors individual care plans.
Coordinates care with other systems, arranges for services, advocates for patients, and provides support. Assists and consults with clients, family members, medical team, and outside agencies in navigating complex service systems such as mental health, medical, HIV community resources, and legal services. Interprets and educates others on complex medical and psychological terminology and reports.
Utilizes thorough knowledge of and participates in the Ryan White HIV care continuum.
Understands and interprets procedures, regulations and legal implications of program services and other various program offerings for clients.
Utilizes a strong knowledge and understanding of harm reduction to provide appropriate behavioral health services and interventions.
Provides thorough assessment and appropriate intervention to clients experiencing mental health crises, suicidal ideation, and active substance use in person and over the phone.
Provides emotional support to clients, partner and family members.
Provides interventions utilizing Motivational Interviewing, Assertive Engagement, trauma-informed approaches, stages of change and psycho-education skills and knowledge to support clients to increase their motivation to address behavioral changes, improve overall health, learn problem solving skills, to improve daily living skills, and to manage emotional and behavioral crises. Includes identifying client goals and development and tracking of care plans.
Evaluates problems interfering with engagement in care and viral suppression, and recommends approaches and techniques to solve those problems.
Documents all work with and on behalf of patients in the electronic health record, including behavioral health visits, telephone encounters and other work.
Assists clients to complete complex forms and to access community resources.
Completes and documents annual reassessments and biannual careplans per Ryan White requirements.
Completes documentation and data collection within stated timelines.
Collects required Ryan White (Health Resources & Services Administration - HRSA) eligibility documentation.
Maintains effective relationships and regularly collaborates and communicates with patients, community partners, and co-workers.
Communicates clearly and concisely, both orally and in writing.