Intensive Clinical Care Manager

POSITION SUMMARY:

Under the direction of the Director of Case Management, the Intensive Clinical Care Manager will provide the appropriate level of coordinated health care services for patients of APLA Health & Wellness.  This position will focus on especially on APLA Health patients that have difficulty staying engaged in primary and HIV medical care due to psychosocial stressors including homelessness, post-traumatic response and other mental health challenges, and/or complicated medical co-morbidities.  The ICCM will connect and engage patients in clinical settings or, as needed, in their homes or elsewhere in the community.   Using a Trauma-Informed lens, the ICCM will outreach and engage patients, complete screenings, link to APLA Health resources that patients may be eligible for and, as necessary, provide ongoing assessment, case planning, and direct case management.  The ICCM will provide services through the Division of HIV and STD prevention.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Plan, coordinate, implement and evaluate a Patient Retention intervention aimed at finding out-of-care APLA Health patients.
• Conduct trauma-focused screenings, provide brief education on trauma, and complete either one-on-one or group psychoeducation classes for patients impacted by trauma.
• Help impacted patients navigate and link to APLA Health resources that they may be eligible for including Medical Care Coordination, Benefits, Housing, and other HIV+ support services.
• Provide behavioral health referrals, advocacy, and service information to patients, as needed.
• Use the Transtheoretical model of behavior change to support improved health outcomes for patients including treatment engagement and retention, medication adherence, risk reduction, and health provider communication.
• Maintain ongoing contact with patients and monitor progress related to goals set in the individual care plan.
• Coordinate and communicate among members of the patient’s care team including medical providers, mental health/addiction providers, allied health, community resources, and other team members. Participate in interdisciplinary case conferences for assigned case management patients.
• Engage in ongoing Trauma-Informed trainings with our community partner, Cicatelli Associates, to stay up-to-date on Trauma-Informed Care best practices.
• Conduct periodic and brief Trauma-Informed Care in-service trainings for clinical staff to help reinforce the cultural practice of Trauma-Informed Care at our clinical sites.
• 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.                                                                

OTHER DUTIES MAY BE ASSIGNED TO MEET BUSINESS NEEDS.

REQUIREMENTS:

Training and Experience:

• A Master’s Degree in Social Work, or Counseling.
• At least one year of experience providing care coordination or case management in either a clinical or a community-based setting.
• Specific training/experience working with people living with HIV/AIDS preferred.
• Bilingual English/Spanish is preferred, but not required

• Experience in working with culturally diverse communities with the ability to be culturally sensitive and appropriate.
• Strong interpersonal skills and the ability to relate to individuals who may not share basic commonalities, including value systems and behavior norms.

• Ability to provide service to individuals with diverse economic, social, racial, and cultural backgrounds

Knowledge of:

• Interviewing and crisis management techniques
• Psychosocial and mental health factors affecting quality of life
• Data management;
• HIV/AIDS prevention, care and treatment, and substance use disorders
• Health education principles and program evaluation.

Ability to:

• Identify and implement outreach and engagement strategies
• Respond effectively to client crisis situations
• Interview and assess needs of clients
• Develop individual service plans aimed toward resolving client needs
• Communicate effectively, both written and verbally
• Work well under tight deadlines
• Coordinate multiple tasks
• Learn specific systems quickly and thoroughly
• Communicate effectively with a diverse population;
• Identify and update community resources;
• Proofread, edit and format written materials;
• Conduct group presentations, operate standard office equipment including Microsoft Office (Word, Excel, PowerPoint); and meet assigned deadlines.

WORKING CONDITIONS/PHYSICAL REQUIREMENTS:

This is both a clinic-based and field-based 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 driver’s license; proof of auto liability insurance; and have the use of a personal vehicle for work related purposes. COVID vaccination and booster or medical/religious exemption.

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

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