RYAN WHITE - MEDICAL CASE MANAGER TIER I, II, or III

*Accepting applicants for Medical Case Manager I, II, or III with the flexibility to work either 60 or 80 hours per pay period subject to applicant availability and preference*

Required years of experience and compensation increase in correlation with tiers

POSITION SUMMARY:

The Medical Case Manager (MCM) on the Ryan White Team serves as a patient advocate for people living with HIV (PLWH). The MCM supports, guides, and coordinates care for patients within a primary care clinic. The MCM manages a caseload of patients, coordinating resources across the care continuum and working to optimize both health outcomes and resource utilization. The MCM facilitates communication among patients, providers, and community-based organizations, ensuring patients receive timely and appropriate care services. This role provides intensive support to patients with the highest needs and includes both clinic and community-based case management support. The MCM is embedded within and an integral part of the primary care team.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Manage a panel of patients to coordinate care and services across ANHC, external specialty providers, and local community resources. Act as a central point of contact, coordinating and integrating services across the service continuum.

• Conduct comprehensive assessments to identify patient’s level of service need and to determine appropriate interventions and support.

• In conjunction with the patient and the primary care team, develop individualized care plans with short and long-term goals to support patients with health goals. Update care plans at appropriate intervals.

• Monitor patients’ progress, evaluate outcomes, and adjust care plans as needed. Assist patients in identifying and accessing needed resources to meet care plan goals.

• Provide ongoing follow-up, support transitions of care (e.g., referrals, follow-up appointments, discharge or changes in care levels), and ensure continuity of care.

• Act as a patient advocate; elevate patient voice so that preferences are respected and needs are met within the healthcare system. Empower patients by highlighting personal agency. Educate patients on rights and responsibilities within a healthcare setting.

• Provide education to patients and their support systems about diagnoses, treatment plans, self-management strategies, and how to access community or social support services. Provide emotional and social support to help patients and their families navigate the emotional toll associated with diagnosis and/or treatment.

• Provide information on screenings, preventative care, and chronic care management. Explain medical information in an easy-to-understand manner, tailoring education to the patient’s health-literacy level.

• Work closely with the primary care team including medical providers, nurses, behavioral health, community resources, and other team members to ensure coordinated, holistic care. Maintain open communication with primary care provider and other members of the care team to ensure

• Maintain accurate, timely, and confidential records of assessments, care plans, interventions, progress notes, and communications. Ensure compliance with legal, ethical, and regulatory standards regarding privacy and data security.

• All other duties as assigned.

SUPPORTING DUTIES AND RESPONSIBILITIES:

• Participates in quality improvement activities. Elevates care trends needing improvement and works collaboratively within a team setting to identify and implement solutions.

• Attends and participates in meetings and activities as required. Serves as a member of site committees, as requested.

• Complete all required trainings as deemed necessary for this position