HIV Care Manager (Bilingual English/Spanish)

Open Door Care Network • Full-time • Ossining, New York State, United States • $25 - $28 / hour • 3w ago

Open Door Care Network provides health care and wellness programs to individuals and families in need throughout Westchester, Putnam and Ulster Counties. A pioneer Federally Qualified Health Center, Open Door provides more than 300,000 patient visits annually and serves nearly 60,000 individual patients who might not otherwise have access. Open Door offers integrated services and a holistic approach to building healthier communities. Primary medical care, dental care, integrated behavioral health care, clinical nutrition, wellness programs, and chronic disease management are the foundation of its clinical programs.

Founded as a free clinic in 1972, Open Door’s mission of building healthier communities through accessible, equitable, culturally competent health care has led to site and service expansions. Today, Open Door operates centers in Brewster, Mamaroneck, Mount Kisco, Ossining, Port Chester, and Sleepy Hollow, in addition to eight School-Based Health Centers in the Port Chester and Ossining School Districts, a mobile dental van in Mount Kisco, and a new dental practice in Saugerties, NY. For more information, please visit our website at www.opendoormedical.org.

Job Summary

As a Patient- Centered Medical Home (PCMH), Open Door Care Network offers a range of case and care management programs designed to deliver comprehensive, coordinated, and patient centered care. With a focus on managing chronic conditions and improving health outcomes, these programs provide a personalized support to patients with the goal of reducing barriers by connecting enrollees with appropriate social and community services. The HIV Case Manager participates in a patient-focused, team-based approach and support patients enrolled in the following programs:

HIV Case Management program which provides comprehensive case management services to people living with HIV/AIDS regardless of insurance status.
The New York State Health Home Program (HH) which is specific for individuals with Medicaid who meet the program eligibility criteria.

Open Door’s Care Managers are part of the medical care team. The primary responsibilities of the HIV Case Manager include conducting assessments, developing care plans and engaging patients in receiving medical, behavioral health and social services.

Duties and Responsibilities

Outreach individuals and engage them into case management services
Conduct assessments to identify individualized needs related to psychosocial wellbeing, physical health and the social determinants of health; utilize standardized assessment tools; monitor needs on an ongoing basis
Based on the findings from the assessments, collaborate with the patient and involved family members/caregivers to set up goals and develop a plan of care
Coordinate and arrange for the provision of medical, behavioral health and social services
Accompany members to appointments as needed with the goal of modeling and coaching on how to navigate medical/behavioral health visits with the aim of empowering individuals to become independent, effective health care consumers
Provide concrete case management services to address barriers to care, including the social determinants of health
Serve as a healthcare system navigator to ensure that patients can access crucial aspects of health care both internal and external to Open Door. Ensures that care is well coordinated and facilitates communication amongst medical providers
Support members in adherence to treatment recommendations from medical and behavioral health providers; addresses medication adherence issues under the direction of HIV medical specialists
Provide research-based education using one-on-one teaching, written and printed materials as well as computer and video instruction to assist members with understanding their HIV/AIDS as well as any other physical and behavioral health conditions (i.e. diabetes, asthma, hypertension)
Assess patients’ confidence and abilities in managing their own health care and navigate the health and social care system
Identify and refer members to available community-based resources and services including prescription assistance program(s); assist patients with applications, insurance, paperwork as needed
Serve as a liaison between HIV medical specialists and patients
Case conferences with HIV medical specialist and follows up with patient and/or HIV medical specialist on identified matters
Document all patient care activities in the electronic medical record and other data bases when applicable in compliance with the guidelines provided by Open Door and following the Policies and Procedures established by the Joint Commission and the DOH for those enrolled in Health Home
Complete Monthly Billing Questionnaires (MBQs) for those enrolled in HH
Participate in patient support group meetings
Discuss advance directives with members and their families or caregivers
Travel to meet with members at their medical/behavioral health appointments, public or community settings, and/or conduct home visits
Meet annual mandatory trainings requirements, including the completion of40 hours annual trainings required for HH staff working with PLWH
Establish and maintain active and positive linkages with other communities agencies and participates in inter-agency meetings as assigned by supervisor
Represent Open Door at community health fairs and community outreach activities to ensure awareness of HIV program services, increase appropriate referrals for HIV prevention counseling and provide current information on HIV and STI prevention and care
Participate in staff development programs, educational activities, seminars, and training opportunities
Participate in team meetings, Quality Improvement meetings and other initiatives as applicable
Conduct other data tracking and reporting activities as assigned
Utilize evidence-based and best-practice techniques on a daily basis in accordance with training (e.g., teach-back method, Motivational Interviewing and SMART [specific, measurable, attainable, realistic, and timely] goal setting)
Other duties as assigned
Informs the Senior Manager, HIV Care & Prevention Programs and the Manager, Case Management Programs of any problems that may affect quality and standards of patient services
Fosters good communication between Open Door and patients by returning all patient telephone requests in a timely manner
Demonstrates ability to function in a culturally sensitive manner within Open Door’s philosophy and mission
Ensures communication among Open Door departments through individual, small group, or department meetings