Medical Case Manager at Avenue360 Health and Wellness – Houston, Texas

About Avenue360 Health and Wellness

Avenue 360 is a FQHC that strives to provide high quality and caring service to promote healthy people and communities. Our 360-degree approach addresses medical needs and social and environmental challenges, like housing. Our compassionate care extends to those with and without insurance. We believe income must not determine the level of access to quality health care.

Providing comprehensive, high quality, and caring service is the core of what we do, whether medical, hospice care, engaging adult activities, and supportive housing programs. We strive to address the many social determinants of healthy living in Greater Houston.

Our Values PACT

• We take PRIDE in our work.
• We have a positive ATTITUDE.
• We are CURIOUS.
• We are COMMITTED.
• We are CARING and CUSTOMER-SERVICE oriented.
• We are a TEAM.
• We LEARN, GROW, and INNOVATE

Overview:

The Medical Case Manager performs client-centered services that link People Living With HIV (PLWH) patient population clients with health care, psychosocial and other services including the coordination and follow-up of medical treatment and counseling. This position performs comprehensive assessments and reassessments, develops individualized comprehensive service plans, conducts service plan implementation and periodic evaluation, performs client advocacy, and reviews service utilization.  

Duties and Responsibilities:

• Conducts comprehensive client assessments and diagnosis at intake and, at minimum, six (6) month intervals to determine social work treatment needs. 

• Establishes specific clinic or program treatment goals such as (1) developing communication patterns with members of other disciplines, and (2) determining priorities for services and the method of services (whether in areas of direct services, consultation, or participant teaching).    

• Develops an individualized service plan in collaboration with the client and/or members of the client’s support system within ten (10) days of the comprehensive assessment to establish goals for addressing crisis, short-term, and long-term identified issues. 

• Communicates with others (internally and externally) to provide, exchange, or verify information, answer questions, and address issues of clients.    

• Documents services provided in client records, the Centralized Patient Care Data Management System (CPCDMS) database, and other database systems as instructed.  

• Ensures data is entered into database systems within prescribed timeframes to satisfy requirements for chart closure and service billing requirements.  

• Compiles and analyzes data for weekly, monthly, quarterly, and annual reports as scheduled or as requested. 

• Participates in, at minimum, four (4) hours of individual and group clinical supervision activities each month. 

• Attends at least one (1) Joint Prevention and Care Coordination meeting each year. 

• Keeps abreast of new knowledge and techniques related to the practice of social work and new medical treatment modalities.    

• Maintains knowledge of internal and external service-related resources. 

• Performs other duties as assigned.   

Education, Licensure/Certification:

• Must be a Licensed Master Social Worker (LMSW) licensed by the State of Texas. 

• Certified Application Counselor (CAC) certification must be obtained within 90-days of hire

Experience, Skills/Abilities Related Requirements:

• Two (2) years volunteer or paid experience in the provision of social work services to individuals living with infectious/communicable diseases, in particular HIV/AIDS clients, is highly desired. 

• Experience with or knowledge of Ryan White initiatives is desired. 

• Must possess excellent oral and written communication skills. 

• Must be proficient in Microsoft Office Suite applications; experience with the CPCDMS and EHR database systems is also desirable.  

• Bilingual in English and Spanish highly desired.

• The minimum number of continuing education (CE) hours to maintain licensure must be obtained annually. 

• Participation in trainings required by the funding source and agency must be satisfied as designated.