The RN Case Manager is a core member of the intensive in-home case management services offered by the Home Health program. Under the direction of the Clinical Nurse Manager, the RN Case Manager works collaboratively with a Social Work Case Manager partner providing the medical case management focus to a caseload of up to 45 clients in order to maintain quality healthcare across the service continuum, decrease fragmentation of care, assist the client to remain engaged in HIV care and treatment, maximize health outcomes, and remain independent in their home or community-based setting.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Receive inquiries regarding participation in the Home Health Program; explain conditions of participation and obtain informed consent from clients to participate in the Home Health Program.
Collaborate with the Social Work Case Manager to assess whether the client is eligible for either Home-Based Case Management Program or Medi-Cal Waiver program via intake interviews including obtaining historical and current medical information. Consult with the Social Work Case Manager in setting the client’s Cognitive Functional Assessment score. Ensure that clients enrolled onto the Medi-Cal Waiver program meet the criteria for Nursing Facility Level of Care as defined by the State California Department of Public Health, Office of AIDS.
Perform initial comprehensive nursing assessment and ongoing reassessments, including client’s current symptoms, risk factors, and an assessment of the client’s level of care for Medi-Cal.
Develop the initial service plan and document the result of the intake in the prescribed format. Work collaboratively with the Social Work Case Manager assigned to the team for team case management. Work with the Social Work Case Manager to solidify the overall service plan for the client. Ensure that clients have input into the plan of care and that the client’s primary care provider is notified of the care plan and start of care.
Document results of the intake, subsequent contacts, reassessments, and all work performed on behalf of the client using our Client Tracking database system (C-Trac).
Consult with the client’s attending physician, primary care practitioner and/or other medical providers as needed to coordinate treatment plan and advocate for the client as necessary.
Identify services available to the client and coordinate services and/or make appropriate referrals as required in the service plan. Document services needed but not available at APLA and refer to other community based organizations.
Monitor the service plan regularly, at least every 90 days with the Social Work Case Manager. Ensure that services are provided based on documented need as evidenced in the assessment and reassessments.
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. Discuss with Program Manager before approaching contracted workers with feedback.
Maintain timely and appropriate contact (as specified in the Joint AIDS Case Management Protocols/County Contracts) with assigned clients. Clients are to be seen minimally every 90 days for face-to-face reassessment, and have contact beyond that as indicated.
Identify and follow up on instances of abuse, neglect, and exploitation that bring harm or create the potential for harm to clients.
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.
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, client confidentiality/HIPAA regulations, ensuring client safety, and maintaining professional boundaries.
Attend case conferences and interdisciplinary treatment team meetings, present reports and collaborate with other team members, document the outcome of the team decisions in the client's chart.
Obtain training annually on topics including HIV/AIDS, medical case management strategies, psychosocial needs, and co-morbid disorders.
Document all actions made on a case in the specific client record in accordance with protocols.
Accurately complete all documents in a timely manner.
Attend unit, division, and other agency meetings as assigned.
OTHER DUTIES MAY BE ASSIGNED TO MEET BUSINESS NEEDS.
Training and Experience:
RN license from State of California. Two years clinical experience post RN licensure required; one year experience in community nursing setting required. BSN and PHN preferred. CPR certification required.
Clinical nursing assessment; home health care procedures; case management practices; health care systems; AIDS and HIV-related illness including common co-morbidities; health care reimbursement mechanisms. Microsoft Office suite including Word and Excel.
Assess biopsychosocial needs, utilize community resources, communicate effectively, participate as an effective member of an interdisciplinary team; conduct sensitive, empathetic interviews; respect the dignity of clients who may have experienced stigma or discrimination; prepare accurate, concise, comprehensive reports; maintain confidentiality of the clients being served; maintain client records in an accurate and timely manner. Demonstrate proficiency with written and verbal communication skills. Meet reasonable deadlines.
WORKING CONDITIONS/PHYSICAL REQUIREMENTS:
This is primarily a field 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. The position requires use of a personal vehicle; up to 50% of the time position will involve driving throughout Los Angeles County, getting into and out of one’s vehicle and meeting with clients in their homes. Some stair climbing and walking uphill is required in getting from one’s vehicle to some clients’ homes. The work schedule is a 4-day 10 hour workweek, and there is no evening, weekend, holiday, or after-hours on-call work required.
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.
APLA Health’s mission is to achieve health care equity and promote well-being for the LGBT and other underserved communities and people living with and affected by HIV. We are a nonprofit, federally qualified health center serving more than 14,000 people annually. We provide 20 different services from 15 locations throughout Los Angeles County, including: medical, dental, and behavioral health care; PrEP counseling and management; health education and HIV prevention; and STD screening and treatment. For people living with HIV, we offer housing support; benefits counseling; home health care; and the Vance North Necessities of Life Program food pantries; among several other critically needed services. Additionally, we are leaders in advocating for policy and legislation that positively impacts the LGBT and HIV communities, provide capacity-building assistance to health departments across the country, and conduct community-based research on issues affecting the communities we serve. For more information, please visit us at aplahealth.org.
A dynamic, diverse staff, a team oriented, collaborative environment, an excellent benefits package, competitive salaries, exciting advancement opportunities, and extensive professional development.