HIV Case Manager

About this role

Department/Unit: Medicine - Aids Program

Work Shift: Day (United States of America)

Salary Range: $70,068.00 - $108,605.00

Case Manager/HIV Department of HIV Medicine Albany, NY

Provides case management services, as needed, to patients under the care of assigned providers. Ensures case coordination, effective use of resources and quality of care in accordance with the HRSA (Health Resource Services Administration) and Albany Medical Center case management standards by performing the following duties.

Education/Experience: Bachelor’s degree in psychology, sociology, social work or related field required; master’s degree in counseling, psychology, or related field preferred.  Minimum of 1 year of documented experience in the provision of case management services to medically compromised patient population, familiarity with community resources and ability to work in a fast-paced, interdisciplinary team setting strongly preferred.    Intake/Assessment: • Conducts age appropriate interviewing with patients identifying needs such as adjustment to illness; financial/employment issues; food, clothing, or housing issues; substance abuse; physical/mental impairments to determine nature and severity of needs; understanding of HIV disease, transmission, and prevention; and behavior change issues.  • Obtains information such as medical, psychological, and social factors contributing to patient's situation, and evaluates these in the context of the patient's strengths, limitations, and family situation. • Assesses and responds appropriately to persons in crisis, intervening to assure safety of patient and others, incorporating an understanding of legal responsibilities in cases of domestic violence and abuse issues.

Education and Supportive Counseling/ Intervention: • Provides education on basic HIV disease concepts, transmission of HIV and sexually transmitted infections, community resources and other issues • Reviews patient’s prevention practices, partner awareness, and partner notification options • Assists patients in developing self-management and health literacy skills • Uses motivational interviewing to impact behavior change relating to HIV transmission, adherence to medications, and other issues • Provides cultural and age-appropriate supportive counseling, on a limited basis, to patient and /or social supports, as indicated, to address needs and mobilize inner strengths • Counsels patients in adjustment to life-threatening illness and its implications, acknowledging issues of diversity and adjusting intervention and practice accordingly • Uses education and collaborative goal setting to help the patient and family understand, accept, and follow medical and psychosocial treatment plans • Informs patients of consumer advisory board and other opportunities to provide feedback on program services • Understands legal issues regarding domestic violence, child abuse, and suicidal/homicidal ideation and intervenes appropriately and in accordance with Albany Medical Center’s policy and NYS law.

Care Coordination/ Interdisciplinary Teamwork: • Assures annual psychosocial assessment via • Distribution of “Emotional Well-being Questionnaire” at annual comprehensive exam • Psychosocial assessment of patient needs at least annually for patients enrolled in grant funded programs

• Develops, monitors, and updates the service plan annually and intermittently as needed. Formulates plans to include specific goals with distinct action steps, as indicated by needs assessment.  • Reviews service plan and performs follow-up to determine quantity and quality of service provided to patient and status of patient's care with specific community providers. • Works in close collaboration with physicians and other members of the healthcare team to further their understanding of significant social and emotional factors underlying patient's health problem • Initiates and annually updates healthcare proxies/living wills with patient • Screens patient for eligibility to entitlement programs, community resources, and internal programs and refers patient to appropriate services/agencies based on identified needs.    • Coordinates case conferences with medical and community agencies as needed. • Assists patients with retention in care • Obtains and updates authorizations for release of information to ensure inter-agency care coordination • Tracks patient status of Paps, annual comprehensive exam (ACE), dental care, and other medical indicators, and works with patients and care team to meet standards of care • Exchanges patient updates/plans with community case managers and provides medical outcome data to community case managers as requested • Communicates patient information/updates to AMC healthcare team using the EHR tasking feature • Refers pregnant patients to family program or Part D program.  Attends OB case conferences (monthly) and monitors pregnant patients closely to ensure scheduling and follow up of prenatal and HIV appointments until family case manager assumes responsibility.  • Meets with or contacts newly diagnosed patients at least quarterly for the patient’s first year in AMC HIV practice, unless this responsibility is covered by other case manager within the DHIVM.  Interactions will focus on patient-identified concerns, retention, adherence, basic HIV education/transmission prevention/HIV resources and screening/addressing barriers to care

Documentation: • Documents assessments, service plans, case conferences, provision of taxi/pharmacy vouchers and other encounters directly in the electronic health record (EHR) or by submitting documents for scanning/filing to the secretary • Enters service data to the AIDS Institute Reporting System (AIRS) • Enters other information to AIRS including, but not limited to, referral, referral status, and pregnancy status • Completes authorizations for release of information with patients and submits for scanning in the EHR • Submits other pertinent documents for sc

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