Patient Care Manager MSW

Job Description

Position Purpose:

The Patient Care Manager (MSW) will be an integral part of the Medical Care Coordination (MCC) and Patient Support Services (PSS) multidisciplinary team, providing non-medical case management activities and services to HIV-positive patients. In collaboration with the Medical Care Manager (RN), Case Worker, Housing Navigator, Peer Navigators, and Retention Outreach Specialist, this position will work closely with other healthcare team members to identify patients' goals, develop treatment plans, address social service needs, and achieve desired outcomes.

The Patient Care Manager (MSW) will be responsible for assessing patients to monitor changes in their status and delivering timely, appropriate interventions as needed. Additionally, the Patient Care Manager will participate in both formal and informal case conferences with the interdisciplinary team, including medical care providers.

Principal Responsibilities:

Conduct bio-psychosocial assessments to identify non-medical needs (e.g., social, emotional, or economic factors) that may interfere with regular HIV medical care utilization, including medical co-morbidities, sexual risk behaviors, substance use history, mental health status, housing, transportation, etc.

Develop a comprehensive, multidisciplinary intervention plan (IP) that includes all Social Determinants of Health.

Ensure the IP is completed within 5 days, including identifying the problem, service interventions, and disposition. The plan will be signed and dated by the patient and updated every 6 months.

Work with the Nurse Case Manager/Clinical Nurse Specialist to identify patients’ unmet medical needs, coordinate with clinic HIV providers, and provide referrals to address gaps or barriers to accessing and adhering to medical care.

Identify patients who have fallen out of care and re-engage them in care.

Utilize the population health registry to manage patients and track trends in overall clinic performance.

Deliver patient education, counseling, and other brief interventions to improve HIV knowledge and reduce the risk of transmitting HIV and/or acquiring other sexually transmitted infections.

Participate in multi-disciplinary health team conferences to formulate the overall patient care plan by interpreting the psychosocial aspects of the patient’s illness.

Write social case summaries and reports documenting the social/emotional assessments, diagnoses, and treatment rendered, in accordance with utilization review standards issued by healthcare regulatory agencies.

Enter and report patient-level data into ACMS CaseWatch in a timely manner.

Co-develop and review an individualized treatment adherence plan with each client.

Maintain client charts and update records as necessary.

Maintain quality assurance standards for the program.

Performs other duties as assigned.

Requirements/Essential Skills:

Master’s degree in Social Work, Counseling, Psychology or related field from an accredited social work program.

MSW’s who is registered with BBS as an ASW will also receive required supervision in accordance with BBS regulations and must adhere to those requirements.

Have two (2) years of experience working with HIV-positive patients.

Ability to work effectively with people of diverse races, ethnicities, nationalities, sexual orientations, gender identities, gender expression, socio-economic backgrounds, religions, ages, English-speaking abilities, immigration status, and physical abilities in a multicultural environment.

Have a working history or educational background, that includes knowledge of STDs, HIV, Hepatitis and/or Tuberculosis within the last five (5) years.

Knowledge of substance abuse and mental health issues and treatment, and related sexual risks.

Have strong interpersonal skills and ability to work well with members of the clinical and case management team.

Able to work independently; think critically; excellent time-management, and ability to make sound decisions.

Able to research, identify, and access community referrals.

Demonstrated experience in extensive methods of follow-up and linked access to services.

Understanding of client confidentiality and legal consequences of failure to abide.

Have experience maintaining confidential information, understand Health Insurance Portability and Accountability Act (HIPAA) requirements, and pass HIPAA certification training for HIPAA compliance.

Preferred:

Experience with ACMS CaseWatch and Electronic Medical Records such as NextGen.

Experience in working with patients who have life altering conditions.

Organized, able to maintain client files, charts, and referral results.

Basic computer skills, knowledge of word processing, data entry, and use of Internet and Internet research.

Strong quality management skills, ensure compliance with all guidelines and regulations.

Bilingual in Spanish preferred; and understanding of multicultural issues.

*All JWCH, Wesley Health Centers workforce members are recommended to be fully vaccinated and boosted against COVID-19.

Employee Benefits:

At JWCH Institute, Inc., we believe in taking care of those who take care of others. If you work 30+ hours per week, you’ll enjoy competitive pay and a robust benefits package that includes:

Medical, Dental, Vision

Monthly employer-sponsored allowance for assistance with health premiums.

Funded Health Savings Account (up to deductible) to assist with carrier-approved medical expenses.

Paid time off (vacation, sick leave) and 13 paid holidays.

401(k) Safe Harbor Profit Sharing plan.

Mileage reimbursement.

Short- and long-term disability plans (LTD/STD).

Life insurance policy & AD&D, and more!

JWCH Institute, Inc + Wesley Health Centers is an Equal Opportunity and Fair Chance Employer.

Full-time