Bilingual Medical Case Manager II (English/Spanish) Hektoen Institute, LLC

JOB SUMMARY The Bilingual Medical Case Manager II will provide a range of client-centered, confidential services that link clients with health care, clinical psychosocial, and supportive service for clients living with HIV/AIDS who are identified as having challenges with accessing and maintaining adherence to health care services. The Bilingual Medical Case Manager II will work closely with the Belmont Cragin and Austin Health Center CBC medical team to stabilize clients’ medically. They will facilitate linkage to and maintenance of clients to their primary medical services. The Bilingual Medical Case Manager II will also provide treatment adherence counseling to ensure readiness for, and adherence to complex HIV/AIDS treatments. This case manager will also provide benefits counseling to clients and assist in enrollment, verification and utilization of those benefits. This staff will function under Cook County HIV Integrated Program, Cook County Health sites, and assist with building the bridge between clinical sites, clients, and the community at large. SPECIFIC RESPONSIBILITIES Complete initial intake and assessment of needs on all new clients and clients returning to care. If opened for CM services, complete AFC intake documentation. Make all initial referrals to Behavioral Health, Health education, dental, and benefits. Assess benefits and complete necessary applications and referrals. Maintain a caseload based on funder requirements. Develop a comprehensive, individualized service plan. Case Manager and client will agree upon goals and objectives for the services plan that will include specific outcomes with expected completion dates and timelines. Case manager will conduct periodic re-evaluations at least once every 6 months review whether the goals were met and should continue or discontinue and/or make new goals if needed. Case manager will collaborate with medical provider and other clinic staff to assure compliance with the service plan. Maintain contact with client to assure Medical and Medication Compliance. Case Manager will contact client prior to scheduled medical appointments to remind them of their appointment. Case Manager will have a face-to-face contact with client at least once every three months and have phone contact with clients monthly in between those face-to-face contacts. Case Manager will conduct outreach if clients become non-compliant by doing phone outreach, sending a letter to last known address, and complete home visits to encourage compliance with medical appointments and medication. Case Manager will advocate and reinforce education to client of the expectations of client around clinic appointments (ensuring client meets with CM at appointment), medication adherence and compliance to all referral to Substance Abuse and Mental Health Services, and other services according to the individualized care plan. Make appropriate and timely referral to internal and external providers and coordinate services identified on individualized service plan. Case manager will make referrals and document in electronic databases. The case manager will follow up on referrals to ensure clients receive the necessary information and support to facilitate their access to these services. Case Manager will meet with Medical Provider on a regular basis to mutually support client’s compliance with appointments. Case manager will be present during clients scheduled medical appointments to advocate on client’s behalf for any identified or assessed services. The Case Manager will attend all pre-clinics to give updates on client’s social service needs and collaborate with other providers. Complete a CM care conference with a licensed provider on all active clients at least once every 6 months. Properly transition clients out of Medical Case Management into other appropriate programs. Complete change of status after meeting all goals of the individualized service plan and the client deemed stable, transfer case into supportive case management or close. If medically indicated, the client should refer to DRS services. The CM will maintain the client on their caseload until the client is accepted into the program. Refer clients to educational support groups if appropriate. If a client would like to transfer to another agency within the Case Management Cooperative, the appropriate transfer steps should be taken per AFC Standards of Procedure. Adhere to Social Services Documentation, CCHIP & Funder’s Policy of all Patient Encounters and Forms. Documentation of all face-to-face, phone calls, and collateral contacts must be in the Electronic Medical Record, and all other databases per funders requirement. All client-related activities, and referrals including approvals and denials should be in EMR (Patient Record) and all other databases per funders requirement. Data Entry and paperwork must be submitted in compliance with the policies. Transportation, food vouchers, cabs, Uber rides must be properly documented in EMR and other databases. A signature receipt from the client should be kept on file for proof of receipt and/or audits. Track any client or service trends and report in monthly supervision. Maintain a Working Knowledge of Community and Internal program that would enhance the client’s ability to be maintained in care. Attend any workshops that would familiarize case manager with community programs. Keep a resource file of HIV/AIDS programs with contact information. Be familiar with ADAP, CareLink, Marketplace insurance, County Care, Medicare D programs and benefits programs that would benefit the clients. Work in collaboration with Community resources to establish a referral process targeting the client population, including but not limited to the City of Chicago and State Programs. Enhance Professional Development and Maintain an Area of Specialization. Discuss areas of specialization and interest with supervisor, seek and receive ongoing training in specialty area (mental health, substance use, housing, women/men specific issues), periodically present cases or topics related to specialty area to case management department and/or social service staff. Maintain professional competencies and complete at least 12 trainings per year. Participate in CCH, CCHIP and AFC mandatory training and meeting. Complete and pass AFC Medical Case Management Certification within first 6 months of employment. Complete all Employee Annual Trainings. Documentation of training completion must be provided to the supervisor. Any trainings that are missed should have documented supervisor approval. Participate in Social Services Continuous Quality Improvement Efforts. Meet documentation requirements as outlined within the Social Services Department and throughout CCHIP. Develop quality improvement processes as assigned. Adhere to CCH, CCHIP, AFC and Social Services Specific Policies & Procedures. Provide Excellent Customer Service and Professionals when interacting with clients and internal and external customers. Respond to phone calls, emails, faxes and pages in according to the CCHIP policies. Maintain open communication with supervisors and communicate concerns through the appropriate means. Other duties as assigned by Supervisor. Provides clinic coverage/general coverage when a shortage arises. Facilitate groups upon request. QUALIFICATIONS – Knowledge/Skills/Experience Minimal Formal Education: Bachelor’s degree in related human service, social science, or health education field from an accredited college or university preferred. Associate’s degree in a related human service, social science, or health education field from an accredited college or university, plus 4 years of case management or related experience required. Minimal Length & Nature of Experience Required: Three to Five years or more experience working with HIV/AIDS/or any chronically ill clients preferred. Experience working in a hospital or out-patient setting preferred. Knowledge and experience working with diverse and complex clients required. Microsoft Office Program, Access, and similar data base experience required. Experience working with clients with multiple needs. Comfortable working with high volumes of clients in a fast-paced environment preferred. Licensure, Certification, Registration Preferred: Licensed or License Eligible in the State of Illinois, LSW or LCSW (If applicable). Special Knowledge and Skills Required and Preferred: Bilingual required English/Spanish. Ability to function autonomously as a worker and as a team member on a multidisciplinary team, excellent oral and written communication skills, problem solving and conflict resolution skills. Knowledge of HIV/AIDS and family issues, commitment to confidentiality, ethics, and a culturally sensitive approach to counseling are required. Experience working in primary care medical settings desirable. AGE-SPECIFICS (Patient Ages and Special Knowledge and Skills): Depending upon assigned specialty area, understand and be aware of the differences in outreach/assessment approaches appropriate to different age groups-in order to provide effective services to CCHIP patients in terms of assessment, developmental understanding, communication and treatment modalities. PHYSICAL DEMANDS/HAZARDS/ENVIRONMENTAL CONDITIONS None EQUIPMENT Ability to use state of the art office tools (telephone voice mail, pagers, and computers used for service area documentation).

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