Medical Case Manager EBNHC · East Boston, MA

Project Shine 79 Paris Street 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. Act as part of clinical care teams to help clients navigate medical care. Conduct readiness to start HIV medications.

• 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.
• 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…