AMAZING INDIVIDUALS WORKING FOR POSITIVE PEOPLE at AIDS Healthcare Foundation!
Does the idea of doing something that really makes a difference in people’s lives while being well-compensated intrigue you? Are you looking to work for an organization that encourages growth and success from each and every one of its employees?
If so, AIDS Healthcare Foundation is the place for you!
Founded in 1987, AIDS Healthcare Foundation is the largest specialized provider of HIV/AIDS medical care in the nation. Our mission is to provide cutting edge medicine and advocacy, regardless of ability to pay. Through our healthcare centers, pharmacies, health plan, research and other activities, AHF provides access to the latest HIV treatments for all who need them.
AHF’s core values are to be:
• Value Employees
• Respect for Diversity
• Fight for What’s Right
STILL INTERESTED? Please continue!
The RN Medical Care Manager is responsible for projecting and integrating the Mission and Core Values of the organization in the provision care management services to members of the AHF/AHFMCO Medicare and Medicaid health plans of California.
Key responsibilities include leading their assigned Medical Care Coordination (MCC) team, consisting of a Patient Care Manager ( PCM) Case Worker (CW) and Patient Retention Specialist (PRS), which provides culturally and linguistically sensitive care management services including medical, psychosocial and socioeconomic needs to the HIV/AIDS special needs population enrolled in the Medical Care Coordination program. The RN MCM will collaborate with the PCM and CW to deliver patient-centered services that focus on addressing health status, engagement and retention in care, adherence to HIV medications, and HIV risk reduction. The RN MCM will participate in interdisciplinary team meetings, participation in activities that increase understanding of the communities served by the AHF/AHF MCO and going the extra mile to assure patients continually gain knowledge helping them achieve their optimum health status and to be sure patients have access and knowledge of the Ryan White Care Act Medical Care Coordination Program, benefits, treatment plan, and medication adherence.
Essential Duties & Responsibilities
Duties and Responsibilities include, but are not limited to:
Responsible to maintain a comprehensive knowledge base regarding the current standards of HIV/AIDS care and case management processes. This will also include a strong working knowledge of the MCC guidelines and the concept of the Integrated Care Services Model.
Collaborates with their assigned Health Care Center (HCC) and disseminates information and education to the HCCs about the MCC program.
Ensures that at least one member of their assigned specific MCC team is physically available on a daily basis to their assigned Health Care Center to assure that MCC services are available to all eligible patients.
Collaborates with their assigned Health Care Center (HCC) team to conduct outreach and assessment activities targeting MCC-eligible AHF clients, ultimately establishing a relationship with MCC-eligible AHF patients, reinforcing the benefits of enrolling in the MCC program.
In conjunction with the Patient Care Manager (PCM), conducts a comprehensive assessment of the patient’s medical, psychosocial and socioeconomic needs. Develops a patient-centered treatment plan based upon the acuity determination from the assessment in concert with the MCC patient, Case Worker, HCC team, patient-identified family/significant other (SO) and other community resources. This will be completed at the HCC, or when appropriate at the patient home or agreed meeting site.
Collaborates with the patient and MCC team (PCM and CW) and HCC team to develop and implement a patient-centered care plan referred to as an Integrated Care Plan (ICP)
Provides education for the MCC patient on HIV/AIDS and other co-morbidities including treatment adherence to medication regimens, including provider appointments, prevention, harm reduction, sexual health and preventative health measures, (PAP smears, PSA screening, etc.)
In conjunction with the patient, the PCM and CW, establishes long and short term goals for the patient/family which are S-M-A-R-T (Smart, Measurable, Achievable, Realistic, Timely)
Responsible to revise the ICP as determined by MCC guidelines and at a minimum following hospitalization of the member, significant change in health status, or following the annual re-assessment.
With the support of the MCC Team, re-engages the patient following hospital admissions and emergency room use through reassessment, coordination of transition of care, including PCP appointment and services as needed.
Provides Transition of Care follow-up visits or calls to patients following change in level of care.
Responsible to monitor the appropriate use of outpatient ancillary services, medication adherence, compliance to PCP visit schedules and results of lab work.
Responsible to monitor patient adherence to medication regimen and attendance of AHF primary care provider visits. Intervenes with member when extended times between ARV refills and/or medical appointments are either “no show” or multiple reschedules that exceed 104 days since last appointment.
Provides education, both verbal and print material, to MCC patient based upon individual need.
Reviews medical records to identify needs and tracks outcomes, e.g., durable suppression of viral load, increase in CD4 count, triglyceride monitoring, Karnofsky scale improvement, etc.
Collaborates with MCC team members to provide referrals for services, utilizing, when appropriate, the resources of other ASOs (AIDS Service Organizations) and additional community services in the eligible Metropolitan Area (EMA), including specialty care providers.
Responsible for the follow-up of said referrals and documentation of outcome (linkage).
Documents effectively in PosiTrak® database system, tracks outcomes of care on an individual and aggregate basis regarding the patient and provider population.
Maintains program records in sufficient enough detail to facilitate and document services rendered to MCC patients.
Monitors patient’s acuity level in an ongoing fashion. Intervenes as necessary. Works to deliver care management services in an efficient and cost effective manner
Maintains patient identifiable health information in a confidential manner and in accordance to AHF policy and HIPAA regulations. Reports all breaches to supervisor.
Participates in the Quality Improvement program by collecting, analyzing and reporting on QI indicators on a routine basis.
Participates in local EMA functions in the community and reports back to management the content and actions of the various committees and groups.
Advocates for patient needs with medical provider, RN Care Team Manager and community.
Reports all complaints and grievances per grievance policy, assists in resolution when appropriate.
Maintains at least the minimum performance and productivity standards.
Other duties as assigned.
Leads and directs the MCC Team as it relates to patient care.
We at AIDS Healthcare Foundation believe that each individual is entitled to equal employment opportunities without regard to race, color, creed, gender, sexual orientation, gender identity, marital status, national origin, age, veteran status or disability. The right of equal employment opportunity extends to recruiting, hiring selection, transfer, promotion, training and all other conditions of employment.