Medical Case Manager

NeighborHealth•Boston, MA

10d•$22 - $33•Onsite

About The Position

The Case Manager is responsible for the overall coordination of services, both internal and external, utilizing a comprehensive approach to address clients' needs and encouraging the full participation of clients' in the development of their individualized service care plans. The target population consists of HIV positive individuals enrolled in Project SHINE. The Case Manager provides care to patients ages 13 to greater than 100 years. Reports directly to HIV Program Manager.

Requirements

Minimum of four years of Human Services delivery experience and/or a Bachelor’s Degree.
Experience working with clients who are HIV positive, have a substance use history and/or have mental health issues.
Knowledge and experience working with diverse communities, specifically men that have sex with men (MSM), recently arrived immigrants, injection drug users and their partners, and adolescents.
Successfully complete course/background in medical terminology.
Good documentation skills.
Good understanding of substance use and abuse.
Demonstrated ability to coordinate services, information and referrals for clients in need of case management services.
Good crisis-intervention and assessment skills.
Strong interpersonal skills.
Good verbal and written communication skills.
Experience with Microsoft Word and Access.

Nice To Haves

HIV Case Management Certification preferred.
Certification as a Substance Abuse Counselor preferred.
Bilingual and bicultural strongly preferred.

Responsibilities

Act as part of clinical care teams to help clients navigate medical care.
Work closely and directly with primary care providers.
Link clients with health care and psychosocial services in a timely and coordinated manner via provision of information and active referrals.
Coordination and follow up of medical treatments.
Provide continuity of care through ongoing assessment of clients’ needs.
Conduct readiness to start HIV medications.
Monitor clients’ adherence to HIV medications.
Conduct initial psychosocial assessment of service needs.
Track visits with Infections Disease Specialist (IDS), make appointments for routine HIV care.
Monitor outside appointments via EPIC and re-schedule them if necessary.
Ensure that specialists have information needed for appointment.
Document face-to-face meetings, phone contact and other forms of communication in EPIC to ensure that all team members have access to information.
Remind clients of internal and outside appointments by phone or letter.
Ensure that interpreters are scheduled when needed.
When interpreters are not available, serve as an interpreter for the NP and IDS.
Share information collected during assessment and reassessments with medical and mental health team members to promote positive prevention, harm reduction and treatment adherence during.
Assess clients' needs and personal support systems with the goal of developing personalized care plans (ISP), incorporating both short and long-term goals.
Present ISP to care team after initial assessment and subsequent reassessments, and incorporate ISP into comprehensive care plan for the client.
Coordinate services required to implement the care plan ensuring non-duplication.
Monitor and re-assess the clients' needs at set intervals and revise care plan accordingly.
Develop linkages with local organizations to exchange information on program-related matters and resources/benefits to strengthen collaborative relationships.
Maintain current, accurate and confidential documentation on patient visits and contacts, including implementation of service plan, in compliance with state and federal regulations.
Collect data necessary for program implementation, evaluation, and reporting.
Prepares for and actively participates in weekly clinical supervision; presents actual case material for discussion, and uses supervision to identify and work on professional goals.
Participate in the process of grant writing activities related to the case management function and service reports re: patient utilization and outcome measures.
Utilizes feedback from clinical supervision to improve work performance.
Participates in required departmental activities and meetings.
Flexibility to adapt to changes in department needs, scheduling and job content.
Performs other duties as assigned.