Summary: This position provides a broad range of specialized medical case management services within a clinic environment according to guidelines established by the Organization and specific programs. This position functions with a high degree of independent accountability, in accord with professional and ethical standards, organizational policies and specific contractual requirements. Populations served will vary by program but may include: children; adults; families; immigrants; refugees; and individuals with mental illness, HIV/AIDS and/or substance abuse issues. Individual accountabilities and work volume will be established through the development of annual Success Objectives, within the framework outlined below.
Essential Duties and Responsibilities:
- Develops and implements program participant treatment plans using experience and understanding of particular chronic medical conditions within a health care setting (medical conditions may vary, some examples include: HIV, Hep C, STI’s, TB)
- Oversees and implements the plans with program participants to ensure that realistic goals and deadlines of accomplishments are being met.
- Provides case management services to program participants through both short-term and long-term case management models and a chronic disease model.
- Receives case assignments, creates case management service plans, reviews case progress and determines case closure through the supervisor of the assigned program and in accord with funder requirements.
- Meets regularly with assigned cases and representatives from community as needed.
- Provides case management follow-up for medical adherence of program participants; including access to medication, medication management and adherence, appointment setting and retention in care, and risk reduction strategies.
- Meets regularly with cross-disciplinary health team to review cases; escalates medical and/or social concerns with medical providers to ensure appropriate medical care decisions and follow-up occurs
- Provides intense advocacy, crisis intervention and problem solving in a variety of areas for all program participants.
- Conducts outreach and intake as required.
- Provides program participants with problem solving assistance and case management support to increase or restore program participant’s capacity for self-sufficiency.
- Develops service plans, which outline a specific plan of action with each program participant under the supervision of the supervisor of the assigned program.
- Makes referrals in accordance with service plans to other Organization units and external providers.
- Screens for income supports for benefits and entitlements to advocate on the behalf of program participants.
- Provides financial assistance and financial management support to program participants, in accord with Organizational policies and procedures.
- Accurately completes in a timely manner all necessary forms, case recordings and statistical reports.
- Develops, monitors and enhances professional relationships with social service, health and governmental agencies.
- Participates and contributes in regular supervision meetings, team meetings, in house training sessions and conferences.
- Participates in program and operational planning.
- Establishes and maintains a professional and therapeutic relationship within the guidelines of professional standards, program participant profiles, confidentiality laws and the newest clinical research available.
- Maintains the volume of work designated by project standards and utilizes strengths-based theory and concepts integration in clinical practice. On an ongoing basis assimilates the knowledge of resources available to implement clinical concepts.
- Adheres to professional standards as outlined by governmental bodies, HRSA, NASW (and/or other appropriate professional associations), private funding sources, Organization plans/policies and Unit guidelines. Participates in periodic evaluative reviews and/or in-house and external staff training to ensure that he/she understands and continues to adhere to such standards. Initiates requests for assistance from Supervisor to address new issues or complex concepts affecting adherence to professional standards.
- Other duties may be assigned.
Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Education and/or Experience: BA/BSW and three years related experience in a health care setting (such as health education, prevention, case management work); or Master’s degree in social work, counseling, clinical psychology or related field.
- Other Skills: A valid drivers license may be required.
- Language Skills: Fluency in a second language may be required if mandated by funder or regulatory agency.
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of organization.
- Mathematical Skills: Ability to add, subtract, multiply and divide in all units of measure, using whole numbers, common fractions and decimals. Ability to compute rate, ratio and percent.
- Reasoning Ability: Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.
Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job, the employee is frequently required to stand; walk; sit; use hands to finger, handle, or feel and reach with hands and arms.
- The employee must occasionally lift and/or move up to 25 pounds.