CKP Ryan White Medical Case Manager

Community Health Center, Inc; Middletown, Northern (CT, KY); On-site; USD 33,000 - 44,000; Full time

Benefits offered by this job

Benefits package

Professional development

Job summary

Community Health Center, Inc is seeking a Medical Case Manager to provide comprehensive, client-centered HIV/AIDS case management under Ryan White Part B Region 3. You will assess, plan, and coordinate care, support treatment adherence, and connect clients to medical and behavioral health services across a multidisciplinary team.

The role emphasizes development of individualized care plans, ongoing client engagement, and data documentation in EHR systems, aiming to improve viral suppression and

Qualifications

• Bachelor’s degree in Social Work, Nursing, Human Services, Public Health, Psychology, or related health/human services field from an accredited college or university required.
• Minimum of one (1) year of experience providing case management, care coordination, or client services in healthcare, HIV services, behavioral health, or community-based settings preferred.
• Bilingual English/Spanish preferred.

Responsibilities

• Conduct comprehensive client assessments identifying medical, psychosocial, behavioral health, housing, financial, transportation, substance use, and other service needs.

Skills

Trauma-informed care

Motivational interviewing

Harm reduction

Client-centered care

Electronic health records

Education

Bachelor’s degree in Social Work, Nursing, Human Services, Public Health, Psychology, or related health/human services field

Tools

CAREWare

Electronic health records

Microsoft Office

Job description

**Job Description:**JOB SUMMARYThe Medical Case Manager (MCM) is responsible for providing comprehensive, client-centered Medical Case Management services to individuals living with HIV/AIDS enrolled in the Ryan White Part B Region 3 Program. The Medical Case Manager supports clients in achieving optimal health outcomes through assessment, care planning, treatment adherence support, linkage to medical and behavioral health services, and ongoing coordination of care.The Medical Case Manager works collaboratively with interdisciplinary care teams, community providers, and support service agencies to ensure continuity of care and improve viral suppression and retention in care outcomes for clients. Services are delivered in accordance with Ryan White Part B Standards of Care, HRSA/HAB National Monitoring Standards, HIPAA regulations, and Community Health Center policies and procedures.**Role and Responsibilities:*** **Medical Case Management Services** + Conduct comprehensive client assessments within required timelines to identify medical, psychosocial, behavioral health, housing, financial, transportation, substance use, and other service needs. + Utilize the Ryan White Medical Case Management Triage Model to determine appropriate levels of case management services. + Develop individualized care plans in collaboration with clients and interdisciplinary providers. + Maintain ongoing monthly contact with clients to monitor progress toward care plan goals and address barriers to care. + Provide treatment adherence counseling and education regarding HIV disease management, medications, viral suppression, prevention strategies, and overall wellness. + Coordinate timely access to medical care, behavioral health services, specialty care, substance use treatment, housing services, transportation, insurance assistance, and other support services. + Facilitate referrals and follow-up with internal and external providers to ensure continuity of care. + Monitor client engagement in HIV medical care and support retention in care efforts. + Conduct reassessments and update care plans at minimum every six (6) months or as clinically indicated. + Participate in discharge planning and transitions of care in collaboration with supervisors and care teams. + Advocate on behalf of clients to reduce barriers and improve access to medically appropriate services.* **Documentation and Data Management** + Maintain accurate, timely, and complete documentation in electronic health records and required Ryan White data systems. + Enter all service encounters, care plans, referrals, and case notes within five (5) business days of service delivery. + Document face-to-face encounters, telehealth visits, phone contacts, referrals, care coordination activities, and treatment adherence services. + Collect and maintain required Ryan White Part B program data, including: - Client demographics - Units of service - Viral load outcomes - Hepatitis B and C screening status - Tuberculosis testing - Mental health and substance use screenings - HIV risk reduction counseling + Participate in Ryan White Services Report (RSR) reporting and other required program reporting activities. + Ensure confidentiality and compliance with HIPAA, Connecticut HIV confidentiality laws, and organizational policies.* **Care Coordination and Community Collaboration** + Collaborate with medical providers, nurses, behavioral health clinicians, pharmacists, outreach workers, and community agencies to coordinate comprehensive care. + Maintain active referral relationships with hospitals, public health departments, shelters, behavioral health providers, correctional facilities, HIV testing sites, and community organizations. + Participate in interdisciplinary case conferences, quality improvement activities, and care coordination meetings. + Support clients with benefits counseling and linkage to Medicaid, Medicare, insurance programs, pharmaceutical assistance programs, and other entitlement services.* **Quality Management and Compliance** + Participate in Clinical Quality Management (CQM) and Continuous Quality Improvement (CQI) initiatives. + Assist with program monitoring activities, audits, corrective action plans, and quality improvement projects. + Attend required Ryan White Part B Region 3 trainings, provider meetings, and professional development opportunities. + Participate in statewide planning and community engagement activities, including the CT HIV Planning Consortium when assigned. + Maintain compliance with all Ryan White payer-of-last-resort requirements and program eligibility standards.* **Caseload Expectations** + Maintain a minimum active caseload of: + 50 clients for Traditional Medical Case Management services + Complete approximately 1,500 client encounters annually. + Perform special assignments, projects, and other duties as assigned by the supervisor.* **Minimum Qualifications** + Bachelor’s degree in Social Work, Nursing, Human Services, Public Health, Psychology, or related health/human services field from an accredited college or university required. + Minimum of one (1) year of experience providing case management, care coordination, or client services in healthcare, HIV services, behavioral health, or community-based settings preferred. + Experience working with individuals living with HIV/AIDS, underserved populations, LGBTQ+ communities, individuals with substance use disorders, mental health conditions, housing instability, or chronic medical conditions preferred. + Bilingual English/Spanish preferred.* Knowledge, Skills, and Abilities + Knowledge of HIV/AIDS treatment, prevention, and Ryan White HIV/AIDS Program services preferred. + Strong understanding of trauma-informed care, motivational interviewing, harm reduction, and client-centered practices. + Knowledge of community resources, entitlement programs, and healthcare systems. + Excellent organizational, communication, documentation, and time-management skills. + Ability to manage multiple priorities and maintain accurate records in electronic systems. + Ability to work independently and collaboratively within multidisciplinary teams. + Ability to maintain strict confidentiality and professional boundaries. + Proficiency with electronic health records, Microsoft Office, CAREWare, and data management systems.Physical Requirements* Ability to travel locally for client visits, meetings, outreach activities, and trainings.* Ability to sit, stand, bend, and use office equipment for extended periods.* Ability to occasionally lift up to 20 pounds.Working Conditions* Work is performed in clinic, community, office, and virtual settings.* Require occasional evening and weekend hours, community outreach, or attendance at off-site meetings and trainings. **Organizational Summary:****Location:**Middletown - Weitzman Building**City:**Middletown**State:**Connecticut**Time Type:**Full time **Compensation and Benefits:**The hourly rate will be 24/hrAt Moses/Weitzman Health System, we are committed to supporting the health, well-being, professional growth, and financial security of our employees. Eligible employees may have access to a comprehensive total rewards package that can include competitive compensation, health and wellness benefits, retirement savings opportunities, paid time off, professional development and tuition assistance programs, employee assistance resources, flexible work arrangements where applicable, and other company-sponsored benefits. Specific benefit offerings and eligibility requirements may vary based on position, work location, scheduled hours, and applicable plan terms. Learn more about our benefits and career opportunities on our Careers website.