Infectious Disease Medical Case Manager

Position: Infectious Disease Medical Case Manager

Location: Nashville (Multiple), TN

Job : 1187

# of Openings: 1

The Infectious Disease Medical Case Manager is a team-based employee who directly supports Neighborhood Health’s patients newly diagnosed with HIV/AIDS (PLWHA), as well as other patients. The role ensures access to assistance programs, related medical services, and social support services. It requires critical thinking, organizational skills, and both written and oral communication to facilitate care and utilize resources along the continuum of care.

Must be able to work in a Patient Centered Medical Home model. Must facilitate partnerships between patients and health team members with focus on care coordination and integration of treatment internally and externally. Must work diligently to ensure that services are accessible, continuous, comprehensive, coordinated, compassionate, and culturally effective. Must be committed to eliminating barriers to care that is centered on the needs and convenience of patients above all other factors.

• Serve as the access point and manage eligibility for Ryan White Part B assistance programs.
• Assist HIV positive patients in applying for Ryan White Part B (or other Parts) programs as appropriate.
• Assist patients in maintaining or applying for all possible third‑party payer programs to include, in order of precedence: private funding/commercial coverage products, Tenn Care/Medicaid, Medicare, and Ryan White Part
  
  B.
• Assist eligible patients to access health‑related services not provided by a private or public healthcare policy and/or by the Grantee. This includes but is not limited to: nutritional counseling, dental care, home health, etc.
• Assist eligible patients to form a clear understanding of their health care coverage to ensure continuity of care and maximization of health care services.
• Coordinate with appropriate community‑based organizations to link eligible patients with social support resources to provide for patient needs. This includes, but is not limited to: food services, housing, and transportation.
• Encourage community service providers to participate in the Medical Services Program as a designated provider for the Ryan White Medical Services Fee Schedule.

• Pro‑actively support PCMH initiatives related to care coordination.
• Work in collaboration with Primary Care Provider and all members of the patient’s Care Team.
• Pro‑active member of care teams in site or organizational team‑based care initiatives.
• Serve as a resource for other clinical staff.
• Partner with PCMH staff to develop integrated care management programs.
• Participate in regular team meetings, staff meetings, and quality improvement projects to improve patient care.
• Report on quality measures to Quality Committee as needed.
• Participate as an embedded member of the Care Team at assigned location.

• Maintain individual records for each patient.
• Submit application to Ryan White Part B in Ryan White Eligibility System (RWES).
• Update patient information in RWES every six months at a minimum.
• Maintain Ryan White Part B patient registry, track Ryan White Part B eligibility and recertify patients for Ryan White Part B every six months at a minimum.
• Act as clinical liaison for Payer Based Care Management programs.
• Input data into CAREWare for the Ryan White Services Report as needed.
• Communicate with Providers across the continuum of care.
• Participate in the evaluation of the Ryan White Part B program(s) throughout the year as requested by Ryan White Part B services.
• Assess patient initial eligibility for Tennessee Ryan White support.
• Conduct comprehensive assessment of patients’ physical, mental, psychosocial needs and psychosocial support systems.
• Determine readiness of patient to participate in treatment.
• Conduct pre‑visit planning for all patients.
• Develop comprehensive care plan in collaboration with care team.
• Implement care plan by assisting patients to navigate the health care system, coordinate specialty care, and follow up on testing.
• Evaluate care plan effectiveness, and evaluate care plan adherence,…