Under the supervision of the Nursing Director, the Clinical Case Manager will coordinate medical and support services for patients who are age 50+ and living with HIV, in consultation with the Medical Director and Supervisor. The Clinical Case Manager will coordinate patient care plans, based on individual assessments, collaborate with other health care team members and the HIVE Program Manager to promote health outcomes.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
• Perform initial comprehensive nursing assessment and ongoing reassessments, including an assessment of the patient’s current symptoms, risk factors, and an assessment of the patient’s level of care.
• Document results of the intake, subsequent contacts, reassessments, and all work performed on behalf of the patient using our electronic health record system (eClinicalWorks).
• Consult with the patient’s attending physician, primary care practitioner and/or other medical providers as needed to coordinate treatment plans and advocate for the client as necessary.
• Identify those services available to the client and coordinate services and/or make appropriate referrals as required in the service plan.
• Coordinate and monitor the service plan, including service providers' performance. Negotiate with service providers when those services have either not been provided, or have been inadequately provided.
• Maintain timely and appropriate contact with assigned clients.
• Identify and follow up on instances of abuse, neglect, and exploitation that bring harm or create the potential for harm to clients.
• Adhere to all applicable professional, legal, and ethical standards of clinical practice in the provision of services, including but not limited to: mandated reporting, provision of effective services, case documentation, patient confidentiality/HIPAA regulations, ensuring client safety, and maintaining professional boundaries.
• Establish working relationships with members of the client's social support systems (e.g. significant others, family members, friends, conservators, etc.). Provide emotional and practical assistance to help them in maintaining their support to the client.
• Identify out of care older HIV-positive patients to reengage them in treatment
• Identify patients’ unmet medical and non-medical needs and coordinate the provision of services.
• Provide patient education based on identified learning needs utilizing available teaching resources.
• Provide and appropriately document health education to patients.
• Participate in quality improvement activities as directed by the medical director, e.g. data analysis and measurement of outcomes, document and report the results and accomplishments of quality improvement initiatives.
• Obtain training annually on topics that address HIV/AIDS, case management, psychosocial needs, and co-morbid disorders.
• Attend unit, division, and other agency meetings as assigned.
OTHER DUTIES MAY BE ASSIGNED TO MEET BUSINESS NEEDS.