POSITION DESCRIPTION

POSITION: Mattapan CARES Medical Case Manager

DEPARTMENT: Mattapan CARES

LOCATION: 1575 Blue Hill Avenue, Mattapan, MA 02126

REPORTS TO: Mattapan CARES Program Manager

TYPE: Full-Time

SALARY: Negotiable

JOB SUMMARY:

The Mattapan CARES Medical Case Manager provides medical case management to adolescent and adult clients with HIV/AIDS with an emphasis on needs assessment, information and referrals, patient education, and intensive advocacy.

RESPONSIBILITIES

90% Client Services:

• Provides Case management services to HIV patients.
• Conducts an initial assessment for HCV and PrEP patients and formulates a plan of care in collaboration with the treating provider and the patient. Revises the plan of care based on an ongoing assessment of the patient's needs and evaluation of the interventions. Coordinates referrals and reviews test/laboratory results.
• Continuously incorporates patient teaching into the plan of care to reinforce the client's knowledge of his/her condition(s), to ensure understanding of the long-term plan and to maintain patient compliance.
• Works collaboratively with nursing personnel and case managers to ensure optimal care throughout the health care continuum. As necessary makes home and/or hospital visits.
• Makes appropriate referrals to community agencies based on assessment of patient needs. Works collaboratively with case manager.
• Meets monthly with other team members. Reports on the patient's progress and makes recommendations on changes to the plan of care to ensure patient compliance and positive patient outcomes.
• Submit monthly activity and variance reports on high risk patients.
• Attends team meetings as needed and as requested by clinical team leaders.
• Completes all paperwork within the required time frame and performs other duties as requested.
• Continuously updates his/her clinical knowledge and skills and maintains continuing education requirements.
• Conducts intake and assessments on new HIV positive clients referred to the health center from a variety of agencies, including hospitals, jails, substance abuse agencies and self-referrals.
• Intakes – serves as the point person/navigator for new patients with HIV and Hepatitis C and PrEP referrals including completing initial screening/intake forms, reviewing new
• referrals with medical staff (HIV/HCV providers and RN), scheduling intake medical appointments and providing navigation services to help new patients schedule and keep their medical appointments.
• Tracking and Follow-up for PrEP and HCV
• Tracks all new PrEP referrals from initial referral/communication.
• Conducts scheduled follow-up communications with patients for adherence and tracking.
• Tracks all appointments, calls and labs in PrEP database.
• Outreaches to patients with missed labs or appointments and works with the team to re-engage them in care.
• Prior Authorizations – completes all PA and/or HDAP forms needed for PrEP and HCV treatment and reviews them with RN or provider and then submits and tracks them through resolution.

10% Community Outreach and Health Promotion

• Works with outreach staff to participate in health center and community-based events to promote HIV, PrEP and HCV services at Codman and engage new patients.
• Works with team members to track routine HIV and HCV testing performance and develop, implement and track strategies to increase routine testing.

Knowledge and experience with HIV services including HIV education/prevention, outreach, counseling, emotional/psychological support and or care management.

Knowledge of substance abuse issues, including detox, rehabilitation and recovery.

Ability to work with a wide range of social service networks.

Experience and ease working with clients in inner city with various ethnic, cultural and racial backgrounds.

Knowledge of basic computer skills such as Word, Excel, Microsoft Outlook, and experience working with electronic medical records.

Demonstrated organizational, oral and written communication skills are required.

Attention to detail with the ability to keep accurate records.

Ability to speak French Creole and/or Spanish highly desirable.

Bachelor’s degree preferred; High School/GED required.

Must cooperate fully with MCHC’s Corporate Compliance Program and performs all tasks as assigned by the Director Family and Community Health Services