Case Manager

Job Description

Job Description

Our Core Values

The culture at Prism Health North Texas is built on our shared Core Values.

We make hiring, firing, promotion and performance review decisions based on these values and behaviors, so it is important that you also share these Core Values:
We are solution seekers.

The organizations founders found solutions even during the AIDS crisis of the 80s; we remain proactive, thrive on change, and always willing to take the lead.
We have a can-do attitude . We are flexible, agile, and never say, Its not my job. We always seek growth, and we are never late but always willing to stay late to see the last patient.
We are mission driven . We are committed to health equity; recognize all contributions are meaningful and valued. It is never about the me or I, but about the we.
We care about people .

We celebrate diversity, equity, and inclusion; we are kind and practice acts of kindness, all in service to our patients and each other.

General Description:
The Non-medical Case Manager (N-MCMC) coordinates psychosocial support services for persons living with HIV/AIDS. The case manager provides a range of client-centered activities focused on improving access to and retention in needed core medical and support services. The N-MCM provides coordination, guidance, and assistance in accessing medical, social, community, legal, financial, employment, vocational, and/or other needed services. The N-MCM provides case management services at all agency locations, offsite locations, within other community-based partner organizations and curbside/home visits when needed. The N-MCM conducts ongoing needs assessment, monitors care plans, documents referral outcomes to support patients towards self-sufficiency. The case management goal with each patient is to obtain viral suppression through a multi-team approach. Responsibilities

Specific Responsibilities of the Job:
Complete the HIV Case Management training series for case management annually.
Complete patient needs assessment to identify unmet psychosocial services needs and determine a case management level/acuity for each patient on caseload.
Obtain all requisite service eligibility documents, consents and provide service coordination to support patients access to services.
Maintain a caseload of patients with documented non-medical case management needs.
Use the established acuity level and initiate ongoing and regular contact with each patient on caseload to determine needs that have been met, unmet, new needs, and barriers to care.
Work with patient to develop a comprehensive care plan based and set goals in collaboration with patient (including their authorized family, significant others, and other social service providers when appropriate), aimed at increasing the level of functioning and self-sufficiency.
Perform psychosocial assessments to identify individualized needs in the areas of health, mental health, social support, addiction, financial resources, benefits, legal, language/culture, and employment.
Provide appropriate and timely nonmedical case management and referral follow up with patients and document referral outcomes.
Work collaboratively with medical, mental health, substance abuse and community service providers as well as any authorized member of the patients care team.
Maintain service continuity and eligibility by completing birth month and half birth month eligibility recertification.
Document and submit patients ready for case assignment to case management supervisors.
Follow-up with patients and authorized families to ensure that services provided are helpful, appropriate, and adequate.
Identify emerging barriers and needs and help patients to address concerns through problem solving, education, referrals, partnership, and advocacy.
Regularly review patients level of involvement in case management, update care plans, and maintain patient contact in accordance with their level of case management need.
Support patients and providers with reviewing and completing various eligibility forms for medications, social programs, other funding sources, etc.
Communicate with each client on a regular basis to determine which needs have been met and to identify any new needs.
Follow established case management standards of care and agency procedures.
Complete accurate and timely documentation of all clients encounters as required and submit all necessary reports to supervisor on time.
Complete an encounter note and log to support patient services delivery daily as proof of daily case management services provided to patients.
Advocates for appropriate services for patients based on needs and assessments.
Identify patients on caseloads ready for case closure or graduation on a frequent/monthly basis and follow established protocol to close or graduate from non-medical case management.
Collaborate with the patient, caregivers, and providers to develop a culturally sensitive case management plan that addresses barriers and promotes improved health outcomes.
Documents each component of the case management process and related activities in accordance with Texas Department of State Health Services (DSHS) Ryan White Service Standards and departmental guidelines.
Maintain concise, accurate and timely documentation that supports effective and efficient case management services delivery.
Work with internal teams to prioritize patient for housing services and perform the following duties:
o Provide supportive case management to patients living in emergency shelters, encampments, rapid rehousing, or permanent supportive housing.
o Complete offsite visits with patients to verify homelessness in areas such as emergency shelters, domestic violence shelters, encampments, and other areas not meant for human habitation.
o Obtain relevant social history, perform needs and safety assessment as patients enter short- or long-term housing programs.
o Prioritize patients who are at risk of homelessness either through eviction or loss of current housing condition.
o Complete housing assessments with individuals or families experiencing homelessness
o Facilitate emergency shelter or hotel placements
o Provide high-quality, trauma-responsive case management services patients
o Manage documentation for 3rd party housing prioritizing into the Homeless Management Information System (HMIS)
o Work with housing partner agencies to prioritize housing services
o Provide supportive case management to patients living in emergency shelters or permanent supportive housing.
Other duties as assigned. Required Skills

Required Knowledge, Skills and Abilities:
Job Requirements:
Proficiency in Excel, Word, and Outlook.
Ability to work in a positive and empathetic manner with persons who have HIV/AIDS.
Working knowledge of

medical/psychosocial

resources and the medical and psychosocial complexities of HIV/AIDS.
Demonstrated knowledge and experience working with clients with mental health and substance use disorders.
Ability to make decisions related to appropriate client care.
Ability to effectively communicate in verbal and written formats.
Ability to collaborate with community service providers.
Ability to establish effective working relationships with clients.
Ability to manage and work effectively in the required electronic medical record, database, or document portal.
Ability to work in a multi-site work environment.
Education and Experience:
A bachelor's degree in social science or behavioral science, nursing, or a related field from an accredited domestic or international college or university.
2 years experience providing case management for people living with HIV or other chronic conditions preferred.
Texas licensure (LMSW or LPC) is preferred.
Bilingual in English/Spanish is preferred
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