Lead Case Manager

General Description

The Non-medical Case Manager (N-MCMC) coordinates psychosocial support services for persons living with HIV/AIDS. The case manager provides a range of client-centered activities focused on improving access to and retention in needed core medical and support services. The N-MCM provides coordination, guidance, and assistance in accessing medical, social, community, legal, financial, employment, vocational, and/or other needed services. The N-MCM provides case management services at all agency locations, offsite locations, within other community-based partner organizations and curbside/home visits when needed.

The N-MCM conducts ongoing needs assessment, monitors care plans, documents referral outcomes to support patients towards self-sufficiency. The case management goal with each patient is to obtain viral suppression through a multi-team approach.

• Complete the HIV Case Management training series for case management annually.
• Complete patient needs assessment to identify unmet psychosocial services needs and determine a case management level/acuity for each patient on caseload.
• Obtain all requisite service eligibility documents, consents and provide service coordination to support patient’s access to services.
• Maintain a caseload of patients with documented non-medical case management needs.
• Use the established acuity level and initiate ongoing and regular contact with each patient on caseload to determine needs that have been met, unmet, new needs, and barriers to care.
• Work with patient to develop a comprehensive care plan based and set goals in collaboration with patient (including their authorized family, significant others, and other social service providers when appropriate), aimed at increasing the level of functioning and self-sufficiency.
• Perform psychosocial assessments to identify individualized needs in the areas of health, mental health, social support, addiction, financial resources, benefits, legal, language/culture, and employment.
• Provide appropriate and timely non–medical case management and referral follow up with patients and document referral outcomes.
• Work collaboratively with medical, mental health, substance abuse and community service providers as well as any authorized member of the patient’s care team.
• Maintain service continuity and eligibility by completing birth month and half birth month eligibility recertification.
• Document and submit patients ready for case assignment to case management supervisors.
• Follow-up with patients and authorized families to ensure that services provided are helpful, appropriate, and adequate.
• Identify emerging barriers and needs and help patients to address concerns through problem solving, education, referrals, partnership, and advocacy.
• Regularly review patient’s level of involvement in case management, update care plans, and maintain patient contact in accordance with their level of case management need.
• Support patients and providers with reviewing and completing various eligibility forms for medications, social programs, other funding sources, etc.
• Communicate with each client on a regular basis to determine which needs have been met and to identify any new needs.
• Follow established case management standards of care and agency procedures.
• Complete accurate and timely documentation of all clients encounters as required and submit all necessary reports to supervisor on time.
• Complete an encounter note and log to support patient services delivery daily as proof of daily case management services provided to patients.
• Advocates for appropriate services for patients based on needs and assessments.
• Identify patients on caseloads ready for case closure or graduation on a frequent/monthly basis and follow established protocol to close or graduate from non-medical case management.
• Collaborate with the patient, caregivers, and providers to develop a culturally sensitive case management plan that addresses barriers and promotes improved health outcomes.
• Documents each component of the case management process and related activities in accordance with Texas Department of State Health…