CKP Ryan White Medical Case Manager

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* Job Description:

** JOB SUMMARY The Medical Case Manager (MCM) is responsible for providing comprehensive, client-centered Medical Case Management services to individuals living with HIV/AIDS enrolled in the Ryan White Part B Region 3 Program. The Medical Case Manager supports clients in achieving optimal health outcomes through assessment, care planning, treatment adherence support, linkage to medical and behavioral health services, and ongoing coordination of care.

The Medical Case Manager works collaboratively with interdisciplinary care teams, community providers, and support service agencies to ensure continuity of care and improve viral suppression and retention in care outcomes for clients. Services are delivered in accordance with Ryan White Part B Standards of Care, HRSA/HAB National Monitoring Standards, HIPAA regulations, and Community Health Center policies and procedures.
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* Role and Responsibilities:

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* ** Medical Case Management Services**  + Conduct comprehensive client assessments within required timelines to identify medical, psychosocial, behavioral health, housing, financial, transportation, substance use, and other service needs.  + Utilize the Ryan White Medical Case Management Triage Model to determine appropriate levels of case management services.  + Develop individualized care plans in collaboration with clients and interdisciplinary providers.  + Maintain ongoing monthly contact with clients to monitor progress toward care plan goals and address barriers to care.  

+ Provide treatment adherence counseling and education regarding HIV disease management, medications, viral suppression, prevention strategies, and overall wellness.  + Coordinate timely access to medical care, behavioral health services, specialty care, substance use treatment, housing services, transportation, insurance assistance, and other support services.  + Facilitate referrals and follow-up with internal and external providers to ensure continuity of care.  + Monitor client engagement in HIV medical care and support retention in care efforts.  

+ Conduct reassessments and update care plans at minimum every six (6) months or as clinically indicated.  + Participate in discharge planning and transitions of care in collaboration with supervisors and care teams.  + Advocate on behalf of clients to reduce barriers and improve access to medically appropriate services.
* ** Documentation and Data Management**  + Maintain accurate, timely, and complete documentation in electronic health records and required Ryan White data systems.  + Enter all service encounters, care plans, referrals, and case notes within five (5) business days of service delivery.  + Document face-to-face encounters, telehealth visits, phone contacts, referrals, care coordination activities, and treatment adherence services.  + Collect and maintain required Ryan White Part B program data, including:
- Client demographics
- Units of service
- Viral load outcomes
- Hepatitis B and C screening status
- Tuberculosis testing
- Mental health and substance use screenings    - HIV risk reduction counseling  + Participate in Ryan White Services Report (RSR) reporting and other required program reporting activities.  + Ensure confidentiality and compliance with HIPAA, Connecticut HIV confidentiality laws, and organizational policies.
* ** Care Coordination and Community Collaboration**  + Collaborate with medical providers, nurses, behavioral health clinicians, pharmacists, outreach workers, and community agencies to coordinate comprehensive care.  + Maintain active referral relationships with hospitals, public health departments, shelters, behavioral health providers, correctional facilities, HIV testing sites, and community organizations.  + Participate in interdisciplinary case conferences, quality improvement activities, and care coordination meetings.  + Support clients with benefits counseling and linkage to Medicaid, Medicare, insurance programs, pharmaceutical assistance programs, and other entitlement services.
* ** Quality Management and Compliance**  + Participate in Clinical Quality Management (CQM) and Continuous Quality Improvement (CQI) initiatives.  + Assist with program monitoring activities, audits, corrective action plans, and quality improvement projects.  + Attend required Ryan White Part B Region 3 trainings, provider meetings, and professional development opportunities.  + Participate in statewide planning and community engagement activities, including the…