The Ryan White Medical Case Manager (MCM) provides comprehensive, client-centered medical case management services to individuals living with HIV. The Medical Case Manager works as part of an interdisciplinary care team to assist clients with accessing and maintaining HIV medical care, medications, health insurance, supportive services, and other resources necessary to achieve optimal health outcomes. The MCM is responsible for assessing client needs, developing individualized service plans, coordinating referrals, monitoring progress, addressing barriers to care, and promoting retention in HIV treatment. Services are provided in accordance with Ryan White HIV/AIDS Program requirements, organizational policies, applicable state and federal regulations, and established standards of care.
Duties & Responsibilities:
• Conduct comprehensive assessments of clients' medical, psychosocial, financial, housing, transportation, insurance, medication, and supportive service needs. • Develop, implement, and regularly update individualized service plans in collaboration with clients. • Establish measurable goals designed to improve engagement and retention in HIV medical care. • Monitor client progress toward service plan goals and revise interventions as needs change. • Provide ongoing medical case management services based on the client's level of need and acuity. • Assist clients in identifying and addressing barriers that may interfere with HIV treatment adherence or retention in care. • Conduct reassessments and service plan updates according to Ryan White Program requirements and agency policy. • Facilitate appropriate transition, discharge, or case closure when medical case management services are no longer required.
• Coordinate services with HIV medical providers, nurses, behavioral health professionals, pharmacists, front desk staff, social workers, and other members of the interdisciplinary care team. • Monitor clients who miss medical appointments and assist with timely re-engagement in care. • Identify clients who are at increased risk of falling out of care and implement appropriate retention strategies. • Support clients who are not virally suppressed by identifying barriers to medication adherence and medical care. • Participate in case conferences and interdisciplinary care team meetings. • Facilitate communication among providers when necessary to support continuity of care. • Assist clients with transitions between healthcare providers, hospitals, specialty care, behavioral health services, and community-based organizations. • Assist clients with accessing and maintaining healthcare coverage and other benefits, including Medicaid, Medicare, private insurance, and other applicable programs. • Assist clients with Ryan White eligibility and recertification requirements as assigned. • Educate clients regarding available Ryan White core medical and support services. • Assist eligible clients with accessing medication assistance programs and other resources when appropriate. • Coordinate referrals for housing, transportation, food assistance, behavioral health, substance use treatment, dental care, legal services, and other supportive services. • Verify that Ryan White resources are utilized appropriately and in accordance with payer-of-last-resort requirements. • Maintain knowledge of community resources and establish relationships with external service providers.
• Educate clients regarding the importance of regular HIV medical appointments, medication adherence, viral suppression, and overall health management. • Utilize motivational interviewing, strengths-based approaches, and other evidence-informed interventions to promote client engagement. • Assist clients in developing strategies to overcome barriers to medication adherence. • Provide education regarding HIV transmission, prevention, treatment, and the importance of achieving and maintaining viral suppression. • Encourage client self-management, independence, and participation in healthcare decision-making. • Complete documentation accurately and within required timeframes. • Maintain comprehensive and confidential client records, including assessments, service plans, progress notes, referrals, eligibility documentation, and supporting documentation. • Enter required information into the organization's electronic health record and/or Ryan White data management system. • Document referrals and follow-up to determine whether services were successfully accessed. • Maintain documentation necessary to demonstrate compliance with Ryan White Program requirements.
• Assist with data collection for the Ryan White Services Report (RSR), quality management activities, audits, monitoring visits, and program evaluations as assigned. • Protect client confidentiality in accordance with HIPAA, agency policies, and applicable federal and state requirements. • Participate in the organization's Ryan White Clinical Quality Management (CQM) activities. • Monitor client-level outcomes related to retention in care, viral suppression, medication adherence, and other established performance measures. • Participate in quality improvement projects designed to address identified gaps in care. • Maintain knowledge of current HRSA HIV/AIDS Bureau requirements, Ryan White Program guidance, and organizational policies applicable to assigned responsibilities. • Participate in chart reviews, internal monitoring, program audits, and corrective action activities. • Assist leadership with identifying service gaps, barriers to care, and opportunities for program improvement. • Maintain records and documentation in a manner consistent with HRSA monitoring expectations.
Minimum Qualifications:
• Bachelor’s degree in social work, Human Services, Psychology, Sociology, Public Health, or a related health or human services field. • Experience providing case management, care coordination, social services, or healthcare navigation services. • Demonstrated ability to work with individuals experiencing complex medical and psychosocial needs.
Preferred Qualifications:
• Bachelor’s or master’s degree in social work. • Previous experience working in a Ryan White HIV/AIDS Program, HIV clinic, Federally Qualified Health Center (FQHC), public health agency, or community-based healthcare organization. • Experience of providing services to individuals living with HIV. • Knowledge of HRSA/HAB Ryan White Program requirements. • Experience with Medicaid, Medicare, health insurance enrollment, medication assistance programs, and community resource navigation. • Experience working within an interdisciplinary medical care team.
Additional Requirements:
• Must be willing to work with SMF EHR, Careware • Must have a valid driver's license • Must be willing to work at different SMF locations if requested • Computer literate in a PC environment, including the ability to end and access data relevant to program, required to include SMF EHR system and Careware The Medical Case Manager may be required to participate in staff meetings, case conferences, community outreach activities, continuing education, quality improvement initiatives, Ryan White monitoring activities, and other program responsibilities as assigned.
Training Requirements:
- The Medical Case Manager will be responsible for attending all mandatory training, including evidence based approaches to self-management support, proactively addressing the needs of patients and families in the community, cultural competency, effective communication, care coordination, HIPAA and EHR, etc. VII. Physical Requirements: (Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions)
