Medical Case Manager

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As one of the largest community health centers in the country, NeighborHealth is proud to serve the greater Boston area with a strong commitment to the health and well-being of our patients and communities.

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Time Type:
Full time

Department:
Project Shine

All Locations:
79 Paris Street

Position Summary:
The Case Manager is responsible for the overall coordination of services, both internal and external, utilizing a comprehensive approach to address clients' needs and encouraging the full participation of clients' in the development of their individualized service care plans.

The target population consists of HIV positive individuals enrolled in Project SHINE.

The Case Manager provides care to patients ages 13 to greater than 100 years.

Reports directly to HIV Program Manager.

Essential Duties & Responsibilities                                              


* Act as part of clinical care teams to help clients navigate medical care.



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* Work closely and directly with primary care providers.



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* Link clients with health care and psychosocial services in a timely and coordinated manner via provision of information and active referrals.



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* Coordination and follow up of medical treatments.



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* Provide continuity of care through ongoing assessment of clients’ needs.


* Conduct readiness to start HIV medications.



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* Monitor clients’ adherence to HIV medications. 

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* Conduct initial psychosocial assessment of service needs.



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* Track visits with Infections Disease Specialist (IDS), make appointments for routine HIV care.



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* Monitor outside appointments via EPIC and re-schedule them if necessary.

Ensure that specialists have information needed for appointment.



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* Document face-to-face meetings, phone contact and other forms of communication in EPIC to ensure that all team members have access to information.



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* Remind clients of internal and outside appointments by phone or letter.



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* Ensure that interpreters are scheduled when needed.

When interpreters are not available, serve as an interpreter for the NP and IDS.



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* Share information collected during assessment and reassessments with medical and mental health team me...