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The Medical Case Manager (MCM) provides client-centered services and implements clinical treatment plans for clients living with HIV who are seeking Ryan White services, including linking clients into medical, mental, and dental care, as well as any other needed healthcare services. Advocates on behalf of clients and ensures the appropriate linkage system with various community agencies and community resources, ensuring timely and coordinated access to medically-appropriate support services. Fosters continuity of care through ongoing assessment of the client’s needs. Assists in engagement of clients into treatment, obtain entitlements and other basic needs, and takes part in discharge planning.

Responsibilities include but are not limited to:

+ Conduct comprehensive bio-psychosocial assessments of clients’ needs and create service plans required to meet those needs utilizing input from the client, medical provider, clinical support staff, and others as appropriate

+ Perform client intake and needs assessment including completion of all required documentation

+ At least twice annually (every 6 months), evaluate and update the client care plan based upon changes to health status and other factors detailed in the reassessment or acuity scale

+ Refer and link clients to the needed medical and/or social services. Monitor the clients’ follow-through with these services in a timely fashion

+ Complete and track applications for basic needs, transportation, housing, treatment programs, and other services in a timely fashion

+ Serve as clients’ advocate in the procurement of benefits and services. Actively advocate on behalf of the clients with community resources

+ Responsible for participating in discharge planning as needed

+ Organize and participate in clinical quality management (CQM) programs per the Ryan White Program requirements. Conduct monthly CQM meetings per Ryan White Program requirements.

+ Track and report all case management activities through the CAREWare system and electronic health record system. Collect and accurately document all required data elements in CAREWare and electronic health record system

+ Perform HIV and Hepatitis C point of care testing as needed and maintain competencies in the same.

+ Perform all other duties as assigned by the ID Program Manager and/or ID Medical Director

Requirements:

+ High School Diploma/GED required. Associate’s Degree or Bachelor’s Degree preferred.

+ Human Service experience is preferred. Excellent working knowledge of New Haven community social and health service agencies is preferred.

+ Excellent organizational skills are required to maintain the caseload. Ability to complete assignments in a timely manner.

+ Ability to interact with patients, staff and outside agencies appropriately. Ability to generate high level of client satisfaction.

+ Knowledge and skills related to individual, group, and family system dynamics are essential. Ability to work as a team member.

+ Knowledge of and demonstration of professional ethics are necessary.

+ Ability to work well with multi-disciplinary service providers. Must demonstrate age-specific and population/cultural-specific competencies in the provision of services to patients living with HIV/AIDS. Must demonstrate cultural competence.

+ Bilingual ability is desirable.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.