Case Manager II; HIV

Overview

TheCase Manager II(CM II), a key member of the primary care interdisciplinary team, provides services for patients with complex care needs. This position conducts patient outreach, engagement and psychosocial service assessment, assists in developing a patient-centered care plan, is the lead implementer of Enhanced Case Management (ECM) and coordinates service referrals and delivery. The Case Manager meets clients in home, clinic, or community as appropriate or required by the specific program/site.

The CM II provides services to specific populations that have multiple complex health and social services needs and often provides care outside of a traditional health center setting, such as home visits, hospitals, supportive housing sites, encampments and shelters.

The primary goal of this Case Manager II (HIV) is to enhance the care of people living with HIV/AIDS (PLWHA) by providing essential support for medication adherence and health maintenance. Responsibilities will include linking newly identified patients to services, re-engaging those who have lapsed in care, and educating individuals in self-care skills. The Case Manager will facilitate access to legal, housing, transportation, mental health, substance abuse, and pain management resources while assisting patients with medical insurance navigation and enrolling them in the AIDS Drug Assistance Program (ADAP).

Additionally, the role involves detailed documentation of client encounters and progress in the electronic medical record system, tracking care outcomes, participating in case conferences, and representing the program at various meetings, all while ensuring compliance with Ryan White and other funding requirements.

This is a full time, benefit eligible position at our West Berkley Family Practice.

This position is represented by SEIU-UHW. Salaries and benefits are set by a collective bargaining agreement (CBA), and an employee in this position must remain a member in good standing of SEIU-UHW, as defined in the CBA.

Life Long Medical Care is a large, multi-site, Federally Qualified Health Center (FQHC) with a rich history of providing innovative healthcare and social services to a wonderfully diverse patient community. Our patient-centered health home is a dynamic place to work, practice, and grow. We have over 15 primary care health centers and deliver integrated services including psychosocial, referrals, chronic disease management, dental, health education, home visits, and much, much more.

Benefits

Compensation: $26.60 - $29.07/hour. We offer excellent benefits including: medical, dental, vision (including dependent and domestic partner coverage), generous leave benefits including ten paid holidays, Flexible Spending Accounts, 403(b) retirement savings plan.

• Outreach, via telephone and in person at Life Long, community and residential sites, to patients who meet case management program eligibility criteria or are prioritized by Life Long for this service
• Proactively meet and engage with patients to build effective relationships and assess strengths and needs through use of standard intake, screening tools, and health, and social services records review
• Actively involve patients and caregivers, as appropriate, in designing and delivering services, including development of care plans, assuring alignment with patients’ values and expressed goals of care
• Provide and facilitate referrals for internal and external resources, and collaborate with the patient to complete required applications, forms, or releases of information
• Maintain a patient caseload in accordance with Life Long standards for the specific population served or site requirements
• Utilize data registries and reports to manage caseload, meet program requirements, maintain grant deliverables, and promote high quality care
• Provide health education and training to patients, including but not limited to, harm reduction and disease risk-mitigation strategies that empower patients to manage their own health and wellness(e.g. overdose prevention, mitigating spread of communicable diseases)
• Assist patients with accessing and retaining public benefits and insurance (e.g. Medi Cal, SSI/SSDI, Cal Fresh, General Assistance), and affordable/subsidized housing
• Respectfully and routinely communicate with patients, their care team members, external partners, and identified social supports
• Maintain knowledge of patients’ medical/behavioral health treatment plans and facilitate utilization of services by providing resources such as accompaniment, transportation, in-home care, reminder calls etc.
• Participate in team meetings to coordinate care, support patient goals, and reducing barriers to accessing services
• Advocate on behalf of patients to get their needs met and/or support patients to learn advocacy strategies for themselves.
• Provide case management services to patients with multiple complex acute or chronic medical or behavioral health conditions (e.g. HIV/AIDS, Hep C, congestive heart…