Under the direct supervision of the RN Medical Care Manager, The MCC Patient Retention Specialist (MCC PRS) is responsible for planning, coordinating, implementing and evaluating patient retention activities to reengage patient living with HIV/AIDS (PLWHA). The PRS collaborates with the MCC team members to identify patients who are eligible for MCC services; will work with the MCC team to promote improved health outcomes for PLWHA.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Plan, coordinate, implement and evaluate a patient retention intervention aimed at finding out of care PLWHA.
- Work with the MCC team in locating out of care patients by conducting outreach services to PLWHA that have fallen out of HIV medical care.
- Schedules follow-up appointments and conducts follow-up activities to ensure patients return for follow-up visits.
- Assist in the coordination and delivery of patient-centered activities that focus on addressing health status, engagement and retention in care.
- Connect patients to services that assist with resolving socioeconomic challenges.
- Assist the medical care manager (MCM) and the patient care manager (PCM) with patient monitoring, following up service linkages.
- Assist the MCM and PCM in updating care plan results, following-up with patients and tracking outcomes.
- Networks, develops strong, productive relationships of transparency and trust with community agencies and organizations, and key stakeholders to establish referral linkages.
- Enters and maintains program data, including clinical documentation and reporting forms.
- Tracks and reports monthly patient service delivery data using Casewatch in a timely manner and prepare other demographic and statistical reports as required by the funding agency and Program Manager.
- Tracks engagement and retention in medical care.
- Document steps taken to help the client maintain access to HIV medical care.
- Responds to patient inquiries in a prompt manner.
- Provide HIV education, inclusive of treatment education.
- Enter progress notes in client-level database systems regarding disposition of clients, referrals, changes of address, telephone information, case manager assignment, etc.
- Assure client confidentiality as defined by APLA policy and procedures.
- Contact appropriate professionals to assist in the determination of need and/or eligibility for services.
- Monitor referrals and follow-up on those requiring additional advocacy.
- Attends staff meetings, MCC meetings (to review and evaluate program services, and make recommendations for program improvement), case conferencing and other meetings as required.
- Attend regularly scheduled in-services, as well as outside conferences, and workshops to expand capacity to meet program goals and objectives.
- Provide written and statistical reports as needed.
OTHER DUTIES MAY BE ASSIGNED TO MEET BUSINESS NEEDS.