POSITION SUMMARY:

Under the supervision of the Nursing Director, the Clinical Case Manager will coordinate medical and support services for patients who are age 50+ and living with HIV, in consultation with the Medical Director and Supervisor. The Clinical Case Manager will coordinate patient care plans, based on individual assessments, collaborate with other health care team members and the HIVE Program Manager to promote health outcomes.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Perform initial comprehensive nursing assessment and ongoing reassessments, including an assessment of the patients current symptoms, risk factors, and an assessment of the patients level of care.
• Document results of the intake, subsequent contacts, reassessments, and all work performed on behalf of the patient using our electronic health record system (eClinicalWorks).
• Consult with the patients attending physician, primary care practitioner and/or other medical providers as needed to coordinate treatment plans and advocate for the client as necessary.
• Identify those services available to the client and coordinate services and/or make appropriate referrals as required in the service plan.
• Coordinate and monitor the service plan, including service providers' performance. Negotiate with service providers when those services have either not been provided, or have been inadequately provided.
• Maintain timely and appropriate contact with assigned clients.
• Identify and follow up on instances of abuse, neglect, and exploitation that bring harm or create the potential for harm to clients.
• Adhere to all applicable professional, legal, and ethical standards of clinical practice in the provision of services, including but not limited to: mandated reporting, provision of effective services, case documentation, patient confidentiality/HIPAA regulations, ensuring client safety, and maintaining professional boundaries.
• Establish working relationships with members of the client's social support systems (e.g. significant others, family members, friends, conservators, etc.). Provide emotional and practical assistance to help them in maintaining their support to the client.
• Identify out of care older HIV-positive patients to reengage them in treatment
• Identify patients unmet medical and non-medical needs and coordinate the provision of services.
• Provide patient education based on identified learning needs utilizing available teaching resources.
• Provide and appropriately document health education to patients.
• Participate 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.
• Obtain training annually on topics that address HIV/AIDS, case management, psychosocial needs, and co-morbid disorders.
• Attend unit, division, and other agency meetings as assigned.

OTHER DUTIES MAY BE ASSIGNED TO MEET BUSINESS NEEDS.

REQUIREMENTS:

Training and Experience: Possession of the following is required: Current CA LVN license, or a valid California Registered Nurse (RN) license preferred, issued by the California Board of Registered Nursing (BRN). Clinical experience in an ambulatory health care clinic, preferably including 2 years of HIV clinical practice. 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. Skill and knowledge to maintain current license/certificate.

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. Knowledge of HIV & Aging issues, including medical, mental health and other psychosocial issues that affect older adults living with HIV.

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 psychosocial assessment and/or working individually with clients in a counseling 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 drivers license; proof of auto liability insurance; and have the use of a personal vehicle for work related purposes.

COVID-19 Vaccination and Booster or Medical/ Religious Exemption required.

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