Infectious Disease Medical Case Manager

Position Summary:

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 Infectious Disease Medical Case Manager is responsible for ensuring access to assistance programs, related medical services, and social support services. This position requires the Infectious Disease Medical Case Manager to use critical thinking skills, organizational skills, written communication, and oral communication skills 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.

Primary Responsibilities:

Serve as the access point and to 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, TennCare/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.

Patient-Centered Medical Home:

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 imbedded member of the Care Team at assigned location.

Medical Case Management Systems:

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.

Direct Patient Care:

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, including prescribed medications adherence Utilize behavioral strategies help patients adopt healthy behaviors and improve self-care in chronic disease management. Promote self-management goals. Provide individual patient/family education and self-management support that is appropriate based on language, cognitive abilities, literacy level, learning style, cultural norms, patient preference, readiness for change and resources available. Follow-up with patients within 24 hours of inpatient discharge & within 48 hours of ED visit notification Partner with external case management programs to coordinate care and identify community resources. Ongoing evaluation and documentation of patient progress/ risk status in EMR; communicate with care teams per established practice guidelines and initiatives. Identify barriers when treatment goals are not met, treatment plan is not being followed or important appointments are missed. Document in EMR

• including pre-visit planning, assessment, and follow-up.

Competencies/Skills:

Demonstrates the following competencies Evidence of comprehensive assessment, problem identification, and care plan development expertise. Experience in chronic disease management with adults and children preferred. Organized and resourceful self-starter; strong ability to work in a team Consistently works to assess and make recommendations for needed clinical system design and development Ability to work independently and exercise clinical judgment in interactions with clinical providers, payers, patients, and their families. Strong organizational and time management skills, as evidenced by a capacity to prioritize multiple tasks and role components. Strong analytical and data management skills. Aware of scope of practice boundaries, comfortable seeking direction, and assistance from appropriate resources. Demonstrates the following Skills Communication

• Ability to communicate effectively verbally and in writing. Excellent negotiation skills, including motivational interviewing and self-management support. Computer Skills
• Proficient ability to use a computer and standard office software. Document in an electronic medical record preferred. Confidentiality
• Maintain patient, team member, and employer confidentiality. Comply with all HIPAA regulations. Customer Service Oriented
• Friendly, cheerful, and helpful to patients and others. Ability to meet patients and others needs while following Neighborhood Health policies and procedures. Decision Making
• Ability to make critical decisions while following Neighborhood Health policies and procedures. Flexibility
• Ability to adapt easily to changing conditions and work responsibilities. Positivity
• Display a positive attitude and is a positive agent for change. Relationship building with patients, staff, and providers. Project Management
• Ability to organize and direct a project to completion. Teamwork
• Work as part of a team and collaborate effectively with co-workers. Working Under Pressure
• Ability to complete assigned tasks under stressful situations.

Qualifications:

A Master's degree in a health or human services related discipline from an accredited college or university with the equivalence of two years of full-time professional case management in a public service agency. OR A Bachelor's degree in Social Work or Nursing from an accredited college or university with the equivalence of two years of full-time professional case management in a public service agency (or a supervised BSW internship may count for one year's experience). OR A Bachelor's degree in a health or human services related discipline and two years of full-time professional case management in a public service agency.

Certification and Licensure:

Current Tennessee Registered Nurse licensure if applicable Current Tennessee Social Work licensure if applicable

Work Environment:

Environmentally controlled medical office environment Fast paced environment with occasional high pressure or emergent situations Work hours subject to office needs to ensure coverage during all hours of operation Possible exposure to bodily fluids, infectious specimens, communicable diseases, toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a laboratory and medical office environment May wear Personal Protective Equipment (PPE) such as gloves or a mask Frequent interaction with a diverse population including team members, providers, patients, insurance companies, and other members of the public

Physical Demands:

Frequent sitting, standing, walking, grasping, carrying, and speaking Occasional reaching, bending, and stooping Lifting, carrying, pushing, and pulling up to 60 pounds, with assistance if needed May need to lift or turn patients who are disabled, with assistance if needed Frequent use of computer, keyboard, copy and fax machine and phone Occasional travel to attend meetings or training