RN Medical Care Manager

POSITION SUMMARY:

Under the direction of the Program Manager, PSS/MCC, provide the appropriate level of coordinated health care services for patients of APLA Health & Wellness. While based at our Gleicher/Chen clinic, the Medical Care Manager also supports patients at our Mid-Wilshire and Michael Gottlieb (West Hollywood) Heath Centers. The RN medical care manager will coordinate with all parties involved in the care of the patient to provide effective and culturally competent care and treatment for people living with HIV and other chronic diseases. The position provides services to persons living with HIV as part of a Medical Care Coordination team and providing case management services for persons with other complex medical needs. The medical care coordination team will target people with HIV who are experiencing medical adherence issues, significant changes in HIV health status or multiple health diagnoses that affect the person’s HIV status. The RN medical care manager in conjunction with the Patient Care Manager, formulates care plans based upon assessment data and provision of care priorities and works in collaboration with the clinical social worker as necessary. The RN medical care manager will coordinate patient care and collaborate with other health care team members to establish the patient’s goals, develop treatment plans and obtain desired outcomes as well as provide patient education based on identified learning needs utilizing available teaching resources.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Provides clinical support and advocacy to HIV+ patients, such as support in improving medication adherence and risk reduction.
• Identifies out of care HIV+ patients to reengage them in treatment
• Performs periodic needs assessments for patients to monitor and update medical needs and to intervene appropriately to support better health outcomes.
• Identifies patients’ unmet medical needs and coordinates with clinic HIV and non-HIV providers to ensure that standards of care are met and any gaps or barriers are addressed.
• Assists in tracking, following up with, and supporting existing and recently enrolled patients
• Identifies patients’ unmet nonmedical needs or barriers to adherence and retention in care, and coordinates with other clinical staff (e.g. social workers) to address needs and barriers.
• Provides and appropriately documents brief interventions focused on patient education, treatment adherence, managing side effects, medical nutrition therapy, co-infections, preventative care and risk reduction.
• Participates 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.
• Assists front office staff in making appropriate arrangements for patients who arrive late for appointments or for whom an appointment needs to be rescheduled, by reviewing the medical record and determining how soon and where the patient should be seen
• Provides health supervision to persons living with HIV and non-HIV on a continuing basis under the consultative direction of a physician

OTHER DUTIES MAY BE ASSIGNED TO MEET BUSINESS NEEDS.

REQUIREMENTS:

Training and Experience:

Possession of the following is required: A valid California Registered Nurse (RN) license issued by the California Board of Registered Nursing (BRN). Must possess current Basic Cardiac Life Support (BCLS) and Cardiopulmonary Resuscitation (CPR) certification. 3 years of RN case management experience preferred, but previous work experience in clinical capacities will also be considered. Demonstrate a history of working with the target population, inclusive of cultural competency and sensitivity, including that of persons living with HIV, and the LGBT community. Experience in chronic disease management, case management, utilization management and quality improvement projects, is preferred. Experience working with electronic health records, working with EClinical Works preferred. Bilingual in Spanish preferred.

Knowledge of:

A solid knowledge of HIV disease, including natural history, symptoms and treatment. Knowledge of substance abuse issues and treatment and related sexual risks.

Ability to:

Ability to research, identify and access community referrals. Demonstrate proficient written documentation skills. Ability to demonstrate basic skills of risk behavior assessment and motivate patients to modify HIV risk taking behaviors and substance use behaviors.

Demonstrate experience in conducting a comprehensive medical-psychosocial assessment and/or working individually with clients in a case management capacity. Ability to provide services in a non-judgmental fashion and work effectively with diverse populations is required as is the ability to maintain records and follow clinical guidelines/protocols. Must be able to work efficiently and complete tasks with a high degree of accuracy; work and solve problems independently; work flexible hours in order to complete tasks and meet client needs. Ability to be flexible in handling unanticipated client needs is required.

WORKING CONDITIONS/PHYSICAL REQUIREMENTS:

This is primarily an office position that requires only occasional bending, reaching, stooping, lifting and moving of office materials weighing 25 pounds or less. The position requires daily use of a personal computer and requires entering, viewing, and revising text and graphics on the computer terminal and on paper.

SPECIAL REQUIREMENTS:

Must possess a valid California driver’s license; proof of auto liability insurance; and have the use of a personal vehicle for work related purposes.

COVID vaccination and booster required or medical/religious exemption.

Equal Opportunity Employer: minority/female/transgender/disability/veteran.