The Health Home Plus (HH+) Care Manager has overall day-to-day responsibility for coordinating the activities of the intensive needs of individuals living with HIV/AIDS who are virally unsuppressed. The HH+ Care Manager is mainly responsible for the delivery of four core services per month (among which are two face to face contacts with the client). The HH+ Care Manager is accountable for coordinating medical care by receiving inpatient and emergency room admissions of targeted clients. In addition, the HH+ Care Manager is in charge of visiting clients during inpatient stays and participating actively in discharge planning and care transition activities.
Essential Job Functions
The following duties are mandatory requirements of the job:
¨ Complete initial and annual comprehensive assessments and develop care plans.
¨ Obtain supportive documentation of clients’ eligibility into the program.
¨ Complete 70 hours of Core Competency Trainings provided by AIDS Institute.
¨ Complete 4 contacts per month among which 2 have to be face to face contacts (or more depending on client needs) with the clients.
¨ Conduct home visits and community follow-up to monitor services and the client’s status.
¨ Participate in case conferences with other providers.
¨ Communicate with MCOs the status of the HH+ clients’ eligibility.
¨ Attend supervisory meetings.
¨ Maintain contact with the client’s extended family and informal support networks.
¨ Escort clients to/from service provider appointments when necessary.
¨ Monitor client’s progress in utilizing services.
¨ Work closely with the interdisciplinary care team including PCP, psychiatrist, therapist, residential services, and substance abuse treatment program.
¨ Conduct care coordination with providers/family for written individualized care plans.
¨ Review client’s intake assessment and uses identified needs to coordinate the completion of the care plan.
¨ In conjunction with the client, the Care Manager is responsible for identifying potential barriers to care and identify possible resolutions to those barriers.
¨ Conduct outreach to clients lost to care.
¨ Evaluate medication compliance and assess potential barriers to adherence; ensure medication reconciliation is current.
¨ Contact clients on the day of discharge from inpatient services and ER within 24 hours.
¨ Outreach to clients to facilitate keeping scheduled appointments; arranges for metabolic and periodic preventive screening, per evidence based guideline standards.
¨ Ensure that clients and care givers are aware of test results by facilitating a discussion between the client and physician.
¨ Coordinate services between client and extended care team providers to ensure that integrated care plan is fully implemented.
¨ Review regularly clients’ information from care team members to identify clients requiring outreach and engagement.
¨ Provide or arrange for provision of self-management/wellness education in the language that the client/family prefers.
¨ Review benefits, entitlements, housing with the client/family and assist in the application process. Follows up as necessary to ensure services are approved.
¨ Assist in crisis intervention.
The following duties are to be performed as assigned by the supervisor:
¨ Participate in CQI activities.
¨ Identify quality of care issues and refers to appropriate departments/services.
¨ Participate in conferences, workshops, and other professional development activities to remain professionally current with advances in field of expertise.
¨ Participate in multidisciplinary task forces, committees, and projects.
¨ Perform other related duties as required.
¨ Bachelor’s Degree in the following fields: social work, psychology, nursing, rehabilitation, nursing, education, occupational therapy, physical therapy, recreation or recreation therapy, counseling, community mental health, child and family studies, sociology, speech and hearing or other human services fields or
¨ Bachelor’s level education or higher in any filed with five years of experience working directly with persons with behavioral health diagnoses, HIV and/or substance abuse or
¨ Master’s Degree in one of the human services field mentioned above.
Two years of experience:
1. In providing direct services to people with Serious Mental Illness, substance abuse, living with HIV/AIDS or
2. In linking individuals with Serious Mental Illness, substance abuse to a broad range of services essential to successful living in a community setting.
A Master’s Degree in one of the listed education fields may be substituted for one-year experience.
Special skills and knowledge
- Excellent computer skills necessary.
- Able to use work processing, spreadsheet and/or database programs as required by the position.
- Knowledge and experience in using electronic databases
- Excellent interpersonal skills.
- Good problem-solving, decision-making, and judgment skills.
- Must read, write and speak English to the extend required by position; fluency in Spanish preferred.
Minimum Education Required