Patient Care Manager
Job Details
Olympic Health Center - Los Angeles, CA
Full Time
Up to 25%
Health Care


Under the direction of the RN Medical Manager, provide the appropriate level of coordinated health care services for patients of APLA Health & Wellness.  Staff will provide and promote health and wellness through the MCC services, and education to people living with HIV/AIDS.  As part of the Medical Care Coordination (MCC) team, and in conjunction with the Medical Care Manager, provides assessment, integrated care planning, and progress monitoring for patients enrolled in MCC.



  • Complete bio-psychosocial assessments; develop a treatment plan, and coordinate appropriate referrals that address the collaborative clinical goals of clinician and patient and document in treatment care plans.
  • Identify high–risk patients, conduct initial screening & risk assessments, conduct intake & assessment, develop a patient centered risk reduction treatment plan with patients; implement documentation according to DHSP requirements.
  • Provide behavioral health referrals, advocacy, and service information to patients.
  • Evaluate patients for eligibility for MCC enrollment.  Determine patient acuity and assist in the development of an integrated care plan to address assessed needs.
  • Conduct brief interventions for MCC-enrolled patients focusing on improving patient’s status as it relates to issues of addiction, mental health distress, risk reduction, and disclosure interventions.
  • Use the Transtheoretical model of behavior change to support improved health outcomes for MCC patients including treatment engagement and retention, medication adherence, risk reduction, and health provider communication.
  • Maintain ongoing contact with MCC patients and monitor progress related to goals set in the individual care plan. 
  • Coordinate and communicate among members of the MCC patient’s care team including medical providers, mental health/addiction providers, allied health, community resources, and other MCC team members.  Participate in interdisciplinary case conferences for assigned MCC patients.
  • Conduct MCC services in accordance with Medical Care Coordination guidelines published by the LA County Department of Public Health, Division of HIV and STD Programs as existing or amended.
  • Screen, assess, and plan appropriate interventions to minimize patient risk of acquiring or transmitting sexually transmitted infections.
  • Document services in eClinicalWorks, Casewatch, and/or other charting and data collection systems as appropriate.  Documentation will be performed in a timely and accurate fashion in accordance with program policies and professional standards of care.
  • Adhere to all applicable professional, legal, and ethical standards of behavioral health practice in the provision of services, including but not limited to:  mandated reporting, provision of effective services, case documentation, patient confidentiality/HIPAA regulations, ensuring patient safety, and maintaining professional boundaries.
  • Attend trainings and case conference meetings as required.
  • Prepare monthly reports and statistics as requested.





A Master’s Degree in Social Work, or Counseling. Knowledge of behavioral health issues and effective treatment modalities; HIV behavioral health issues; ability to perform differential diagnosis using the DSM-V; various theoretical orientations; treatment modalities; clinical techniques and interventions; treatment planning; biopsychosocial assessment; crisis intervention and reporting obligations; HIV risk reduction counseling; HIV Prevention strategies; reporting obligations and available community services and resources; motivational interviewing, theories of change and harm reduction methods.


Ability to:

Communicate effectively orally and in writing; organize work in an effective manner; work in a collaborative, interdisciplinary, fast paced environment; work effectively independently and as part of a team; communicate and relate to a variety of personalities, ethnicities, and sexual orientations; complete documentation in a comprehensive and timely fashion in accordance with APLA H&W policies.



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.



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.


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