Job Description Summary:

Job Description:

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.

Role and Responsibilities:

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 CT HIV Planning Consortium when assigned.

Maintain compliance with all Ryan White payer-of-last-resort requirements and program eligibility standards.

Caseload Expectations

Maintain a minimum active caseload of:

50 clients for Traditional Medical Case Management services

Complete approximately 1,500 client encounters annually.

Perform special assignments, projects, and other duties as assigned by the supervisor.

Minimum Qualifications

Bachelor's degree in Social Work, Nursing, Human Services, Public Health, Psychology, or related health/human services field from an accredited college or university required.

Minimum of one (1) year of experience providing case management, care coordination, or client services in healthcare, HIV services, behavioral health, or community-based settings preferred.

Experience working with individuals living with HIV/AIDS, underserved populations, LGBTQ+ communities, individuals with substance use disorders, mental health conditions, housing instability, or chronic medical conditions preferred.

Bilingual English/Spanish preferred.

Knowledge, Skills, and Abilities

Knowledge of HIV/AIDS treatment, prevention, and Ryan White HIV/AIDS Program services preferred.

Strong understanding of trauma-informed care, motivational interviewing, harm reduction, and client-centered practices.

Knowledge of community resources, entitlement programs, and healthcare systems.

Excellent organizational, communication, documentation, and time-management skills.

Ability to manage multiple priorities and maintain accurate records in electronic systems.

Ability to work independently and collaboratively within multidisciplinary teams.

Ability to maintain strict confidentiality and professional boundaries.

Proficiency with electronic health records, Microsoft Office, CAREWare, and data management systems.

Physical Requirements

Ability to travel locally for client visits, meetings, outreach activities, and trainings.

Ability to sit, stand, bend, and use office equipment for extended periods.

Ability to occasionally lift up to 20 pounds.

Working Conditions

Work is performed in clinic, community, office, and virtual settings.

Require occasional evening and weekend hours, community outreach, or attendance at off-site meetings and trainings.

Confidentiality of Information

Confidentiality of business information is a requirement. Confidentiality must be maintained according to CHC policies.

Organization Information:

The Moses/Weitzman Health System is a global leader addressing challenges faced by organizations caring for the poor and diverse populations, and is home to programs focusing on education, research, and process improvement support for safety net providers. The system delivers primary care to more than 150,000 patients in Connecticut, and extends access to specialty care for more than 2.5 million individuals across the U.S. It is a national accrediting body for organizations training advanced practice providers, and offers accredited education and training for Medical Assistants in multiple states. As an incubator for new ideas in areas including social justice, the environment, and social determinants of health, the MWHS is addressing challenges faced by providers caring for underserved communities, creating innovative and impactful initiatives led by nationally and internationally recognized experts. As it forges pathways into the future of primary care, the MWHS honors Lillian Reba Moses (1924-2012), a granddaughter of slaves, and Gerard (Gerry) Weitzman (1938-1999), whose ancestors escaped pogroms in Eastern Europe. Their vision and commitment to justice and equity in healthcare is the foundation upon which the Moses/Weitzman Health System was built.

Location:

Connecticut Pediatrics @ CHC - Hartford

City:

Hartford

State:

Connecticut

Time Type:

Full time

MWHS provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any @type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

Moses/Weitzman Health System

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