PHMC serves as both a direct service provider to individuals, families, and communities across the region and as an intermediary agent — managing large-scale contracts, government and philanthropic partnerships, and multidisciplinary initiatives that require operational sophistication, strategic leadership, and deep mission alignment. The Medical Case Manager is responsible for the coordination of care for clients who are diagnosed with HIV/AIDS at the Care Clinic.
Requirements
- Maintain a caseload of approximately 50 active clients.
- Act as a liaison between clients and the physician. Advocate as appropriate.
- Complete standardized AACO MCM assessment within 3 days of referral from Client Services Unit.
- Develop a Medical Care Plan using the AACO standardized Service Care Plan template.
- Provide a treatment adherence and health literacy assessment at intake and during annual Comprehensive Assessment.
- Conduct Treatment Adherence Counseling at least quarterly.
- Identify barriers to medical care and make appropriate referrals to address these issues (i.e., d/a facility, mental health program, care outreach services, etc.).
- Attend medical appointments with each client at least once every 90 days.
- Conduct one home visit for each client annually.
- Maintain and update required paperwork, flow sheets, signatures, and documentation.
- Coordinate with Care Team and Patient Navigators to provide support in locating those lost to care.
- Collaborate with an interdisciplinary team in the evaluation of patient needs and treatment progress.
- Maintain chart documentation (DAP format) to assure timely and accurate communication with team members (documentation in CareWare within 48 hours).
- Assess patient needs and complete referral process to appropriate social services agencies (i.e., drug/alcohol sites, mental health crisis response centers, etc.).
- Enter and update information on the CareWare database for monthly grant reporting requirements (provide 4800 service units annually / 400 units of service per month).
- Attend internal and external trainings and meet training requirements to complete a minimum of 20 hours of continuing education annually in accordance with funding requirements. Submit proof of attendance hours to the AACO Education Coordinator.
- Close cases when services are no longer indicated, or if more than 3 months have passed since the client initiated contact.
Benefits
- Generous Paid Time Off
- 401k Matching
- Retirement Plan
