Case Manager at Brooklyn Plaza – Brooklyn, New York

Position Summary:
The Medical Case Manager will work closely with clients living with HIV/AIDS who have multiple psychosocial and/or health related needs. Medical Case Management services is a strength based approach to service that includes treatment adherence counseling, coordination and follow-up of medical treatments, client advocacy, and assistance in obtaining housing, financial support, legal services, social support and any other needed service. The goal of Medical Case Management is to ensure that clients with HIV/AIDS have timely access to comprehensive medical care and social services; prevent disease transmission and delay HIV progression and promote and support client independence.
Screening
1. Collaborate and Consult with Clinical Staff to identify current clients who are in need of medical case management services.
2. Works with agencies in the HIV/AIDS service system to engage individuals infected with HIV.
3. Responds to requests for case management services.
4. Conduct intake during the initial medical appointment.
5. Conduct rapid HIV and Rapid Hep C testing on site and off site.
6. Complete the screening to determine eligibility for medical case management services.
7. Collaborate with the HIV department to generate referrals for Prep/Pep services
Orientation and Assessment
1. Provide an overview of case management services including the role and responsibility of the case manager and the client.
2. Completion of the comprehensive assessment, to determine the client’s strengths, resources, needs and problems.
3. Work with client to develop an individual Care Plan which includes realistic, measurable and mutually acceptable goals that are based on the results of the assessment.
4. Identify action steps needs to achieve each goal, including target dates for accomplishment of the stated goals.
5. Identify referrals made to other providers/services in connection with action steps.
Referrals and Case Coordination
1. Attend and participate in HIV Collaborative Meetings as scheduled.
2. Identify and contact community based organizations, primary care providers, housing services and other needed providers to establish referral agreements and to coordinate collaborative efforts with clients.
3. Complete all documentation to show evidence of the time, date, place and description of each case management service.
4. Document progress made toward goals by writing notes in electronic medical records.
5. Generate referrals for Care coordination within Brooklyn Plaza Medical Center HIV department.
Continued Contact
1. Face to face interaction with client, as required by level of needed support.
2. Complete the Care Plan biannually; making any changes, additions or deletions to current services.
3. Obtain clients signature on Care Plan review indicating the agreement for continued contact and case management services.
4. Develop intervention plan to re-engage client if face-to-face contact is not maintained and include the intervention in the Care Plan.
5. Document treatment adherence activities, and harm reduction counseling in client’s file; these include keeping medical appointments, taking prescribed medication, refilling prescriptions, etc.
6. Assist the HIV department in the collection of data and completion of reports as necessary.
Knowledge, Skills and Abilities
1. Excellent customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.
2. Excellent verbal and written communication skills.
3. Bilingual in Spanish/English preferred
4. Excellent computer skills, experience with electronic medical records a plus.
5. Ability to interact with patients, staff and outside agencies appropriately.
6. Ability to follow instructions, given either orally or in writing.
7. Ability to work independently or with little supervision.
8. Excellent organizational skills such as problem solving, decision making and priority setting.
9. Ability to complete assignments in a timely manner.
10. Ability to work as a team member.
11. Ability to maintain HIPAA compliance, corporate compliance and client confidentiality.
12. Ability to work Weekends and late nights when necessary.

Education, Training and Experience
• Minimum High school Diploma with 2 years of case management experience.
• Knowledge of Word and Excel.
• Minimum 2-year experience of providing social services assistance to underserved communities.