Job Description
Job Description
The medical case manager (MCM) acts as a patient advocate and care coordinator, helping individuals navigate the complexities of the healthcare system to achieve optimal health outcomes. They assess patients' needs, develop individualized care plans, and connect them with appropriate resources, including medical, social, and financial services. Case managers also monitor patient progress, facilitate communication between various healthcare providers, and advocate for patients' rights and
preferences. The medical case manager is responsible for managing a client caseload, coordinating and monitoring external referrals, submitting monthly and quarterly reports, and conducting client data entry and reporting. The MCM works directly with women living with HIV/AIDS, their partner(s) and self-defined family members to support them in accessing medical, psychological, and social services to positively affect their health outcomes and ability to remain in care and treatment.
Key Responsibilities:
Assessment: Conduct comprehensive medical and biopsychosocial assessments to identify barriers to care and inform service planning.
Care Planning: Develop and maintain individualized medical service plans in collaboration with clients, healthcare providers, and the interdisciplinary care team.
Resource Coordination: Coordinate referrals to medical, behavioral health, and supportive services, working closely with non-medical case management staff and community partners.
Communication and Collaboration: Facilitate communication among clients, healthcare providers, insurers, and partner organizations to ensure continuity of care.
Advocacy: Advocate for clients’ rights and support navigation of complex healthcare and social service systems.
Monitoring and Evaluation: Monitor client progress, including treatment adherence and health outcomes, and update care plans as appropriate.
Discharge Planning: Support discharge planning as needed to ensure continuity of care and access to appropriate services.
Education and Support: Provide client-centered education related to health conditions, treatment adherence, and available resources.
Duties: 1. Assist in building client base for medical case management system. Facilitate access to intake screening and follow up interviews for clients.
2. Assess clients’ medical and bio-psychosocial needs, including, but not limited to medical/mental health services, treatment adherence, housing, psychosocial support, home health/respite care, legal services, etc., while coordinating closely with non-medical case management staff
3. Develop and maintain individualized medical service plans for assigned clients, including referrals to medical, behavioral health, and supportive services, in coordination with non-medical case management staff and community partners (s).
4. Monitor client progress including tracking viral load and CD4 count, maintaining dialogue with the physicians and/or collateral care providers.
5. Coordinate treatment adherence activities for clients as part of the interdisciplinary care team; provide individual adherence support within medical case management; and co-facilitate adherence-related group sessions
6. Reinforce HIV risk reduction education with clients as part of ongoing medical case management, while primary prevention education and behavior change programming are delivered by HIV prevention and education staff.
7. Provide crisis support, stabilization, and referrals for medical case management clients, in collaboration with non-medical case management staff and supervisory personnel.
8. Conduct ongoing monitoring and reassessment for assigned clients related to medical care engagement, treatment adherence, and health outcomes, with referrals and service coordination conducted collaboratively across the care team.
9. Maintain clear, accurate, timely documentation for assigned medical case management clients in CARE Ware and required case files, contributing case-level data to support program reporting in collaboration with program and evaluation staff; support leadership in meeting, funder requirements, and agency-wide initiatives.