Public Health Medical Case Manager, Infectious Disease

BMC Company 100; Boston (MA); On-site; USD 70,000 - 100,000; Full time

Job summary

Boston Medical Center seeks a Public Health Medical Case Manager to support HIV-positive patients in the infectious diseases program. The MCM conducts acuity assessments, helps with insurance, and develops ISPs to meet identified needs, coordinating with social services to improve engagement in care.

Working in the HIV Clinic, the MCM ensures data accuracy in the EMR, tracks progress, and advocates for patients to access benefits, housing and transportation while supporting adherence and

Responsibilities

• Acuity assessment and income verification are non-negotiable eligibility requirements by MDPH in order to provide MCM services to any client.
• Collects income verification on all patients, obtains back up documentation from patients and documents it appropriately every 6 months.
• Performs acuity assessments based on the MDPH acuity scale at least every 6 months or more often as the patient's needs change.
• Refers patients to the appropriate tier of service based on acuity scale (basic, moderate, intensive).
• The MCMs will mostly work with moderate need patients but have the ability to work with all levels of need.
• Individual Service Plans (ISPs) are a non-negotiable eligibility requirement by MDPH in order to provide MCM services to any moderate or intensive need client.
• Assesses patients' needs and develops flexible service plans (ISPs) and maintains regular updates of these plans, at least every 6 months or more often as needs change.
• Work with patients on the ultimate goal of self-management.
• Ensures that patients have and maintain HDAP coverage and other medical insurance necessary for engagement in care and work in concert with the Benefits Navigator team.
• Proactively work with patients anticipating their needs in advance and apply for services in advance if possible.
• Proactively conduct chart reviews the week before clinic to assess needs of patients and remind them in advance of things they can do to prepare for their appointments.
• Follow-up with patients in a very active manner, reminding them of plans or activities discussed.
• Maintains an active caseload of patients and if patients no show/fall out of care work with the ARCH teams on re-engagement in care.
• Conducts comprehensive and ongoing risk assessments and engages patients in risk reduction and positive prevention discussions and activities in context of the acuity reassessments.
• Addresses concrete service needs and encourages engagement into systems as needed.
• Links patients to a broad range of services, including, but not limited to: HIV support services, including community-based case management; substance abuse treatment; mental health services; financial assistance; housing; food; financial entitlements; clothing; and transportation.
• Monitors patients' progress via patients' level of functioning, adherence to treatment plans, recovery/relapse process, and service needs.
• Performs and maintains all documentation in the electronic chart of patient encounters; resource development efforts; and other patient interventions and interactions, utilizing MDPH service codes for all such documented activities.
• Works with technical/data team on proactively tracking and monitoring compliance of the contract mandates for their patients.
• Writes notes appropriately in the EMR and signs notes within 48 hours per hospital standards.
• Document all work done by MDPH mandated service codes in the EMR.
• Develops and maintains strong relationships with community resources to ensure patient access.
• Assists with immigration and refugee issues; works with refugee services for coordination of concrete services and support.
• Assists with interpreter scheduling/coordinating.
• Collaborates and coordinates with medical and mental health team members to promote positive prevention, harm reduction and treatment

Job description

Position : Public Health Medical Case Manager

Department : Research - Infectious Diseases

Location: Boston, MA

Schedule : Full Time

POSITION SUMMARY :

This position is a special role designed for the Public Health programs. The Medical Case Manager (MCM), Public Health Programs, is located in the Center for Infectious Diseases' HIV Clinic and is responsible for providing medical case management services for HIV positive patients. The MCM is responsible for conducting comprehensive acuity assessments for all HIV-infected patients based on the Massachusetts Department of Public Health (MDPH) required acuity tool. The MCM is responsible for collecting income eligibility for all patients they serve as part of program eligibility requirements. The MCM will provide comprehensive insurance assistance, risk and transmission counseling, medical, adherence, and treatment counseling; developing individual service plans (ISPs) based on those identified needs; facilitating referrals and access to social service benefits, concrete services, and other providers; monitoring patient progress and advocating on behalf of patients when they are unable to do so for themselves; complying with all data entry, data integrity, and data tracking requirements for BMC and MDPH (or other funder) contract monitoring reports. MCMs are expected to possess and utilize critical thinking and clinical skills in order to engage and retain patients in care, to reduce HIV viral loads and transmission risk. All MCM notes will be written in the appropriate format in the EMR. The MCM conducts all activities within the standards, regulations, and contract assurances of the MDPH contract.

JOB RESPONSIBILITIES :

• Acuity assessment and income verification are non-negotiable eligibility requirements by MDPH in order to provide MCM services to any client.
• Collects income verification on all patients, obtains back up documentation from patients and documents it appropriately every 6 months.
• Performs acuity assessments based on the MDPH acuity scale at least every 6 months or more often as the patient's needs change.
• Refers patients to the appropriate tier of service based on acuity scale (basic, moderate, intensive).
• The MCMs will mostly work with moderate need patients but have the ability to work with all levels of need.
• Individual Service Plans (ISPs) are a non-negotiable eligibility requirement by MDPH in order to provide MCM services to any moderate or intensive need client.
• Assesses patients' needs and develops flexible service plans (ISPs) and maintains regular updates of these plans, at least every 6 months or more often as needs change.
• Work with patients on the ultimate goal of self-management.
• Ensures that patients have and maintain HDAP coverage and other medical insurance necessary for engagement in care and work in concert with the Benefits Navigator team.
• Proactively work with patients anticipating their needs in advance and apply for services in advance if possible.
• Proactively conduct chart reviews the week before clinic to assess needs of patients and remind them in advance of things they can do to prepare for their appointments.
• Follow-up with patients in a very active manner, reminding them of plans or activities discussed.
• Maintains an active caseload of patients and if patients no show/fall out of care work with the ARCH teams on re-engagement in care.
• Conducts comprehensive and ongoing risk assessments and engages patients in risk reduction and positive prevention discussions and activities in context of the acuity reassessments.
• Addresses concrete service needs and encourages engagement into systems as needed.
• Links patients to a broad range of services, including, but not limited to: HIV support services, including community-based case management; substance abuse treatment; mental health services; financial assistance; housing; food; financial entitlements; clothing; and transportation.
• Monitors patients' progress via patients' level of functioning, adherence to treatment plans, recovery/relapse process, and service needs.
• Performs and maintains all documentation in the electronic chart of patient encounters; resource development efforts; and other patient interventions and interactions, utilizing MDPH service codes for all such documented activities.
• Works with technical/data team on proactively tracking and monitoring compliance of the contract mandates for their patients.
• Writes notes appropriately in the EMR and signs notes within 48 hours per hospital standards.
• Document all work done by MDPH mandated service codes in the EMR.
• Develops and maintains strong relationships with community resources to ensure patient access.
• Assists with immigration and refugee issues; works with refugee services for coordination of concrete services and support.
• Assists with interpreter scheduling/coordinating.
• Collaborates and coordinates with medical and mental health team members to promote positive prevention, harm reduction and treatment