Patient Care Manager II - APLA Health

POSITION SUMMARY:

Under the direction of the MCC Coordinator,the Patient Care Manager II (PCM II) will provide culturally competent services to low-income adult individuals in Los Angeles County, with a specific focus on the LGBT community and other underserved communities.Will provide and promote health and wellness through the MCC services, and education to people living with HIV/AIDS and other chronic diseases. As part of the Medical Care Coordination (MCC) team, and in conjunction with the Medical Care Manager, provides assessment, integrated care planning, and progress monitoring for patients enrolled in MCC.In addition, the PCM II will work closely with the Director of Case Management andMCC Coordinatorto design, implement and monitor workflow processes at the MCC department.The PCM II will coordinate patient care and collaborate with other health care team members to establish the patient’s goals, develop treatment plans and obtain desired outcomes as well as provide patient education based on identified learning needs utilizing available teaching resources.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Provide oversight, guidance, and provides leadership to MCC team.

• Ensures contractual compliance.
• Prepare quantitative and qualitative reports
• Enter MCC data into DHSP data programming system and submitted in a timely manner.
• Contributes to data collection to measure quality and performance.
• Setting yearly program objectives/goals.
• Submitting monthly and year end reports .
• Provides supervisory duties to program staff including, but not limited to:

• Hiring
• Training of new hires
• Conducting employee evaluations
• Ensures that program staff are kept up to date on MCC program progress
• Dispensing disciplinary action up to and including the termination of program staff.
• Approval of time off/vacation requests

• Develop staff training plans
• Works in collaboration with the Nursing Director &MCC Coordinatorto ensure on-going trainings and educational needs of MCC staff are met.
• Complete bio-psychosocial assessments; develop a treatment plan, and coordinate appropriate referrals that address the collaborative clinical goals of clinician and patient and document in treatment care plans.
• Identify highrisk patients, conduct initial screening & risk assessments, conduct intake & assessment, develop a patient centered risk reduction treatment plan with patients; implement documentation according to DHSP requirements.
• Provide behavioral health referrals, advocacy, and service information to patients.
• Evaluate patients for eligibility for MCC enrollment. Determine patient acuity and assist in the development of an integrated care plan to address assessed needs.
• Conduct brief interventions for MCC-enrolled patients focusing on improving patient’s status as it relates to issues of addiction, mental health distress, risk reduction, and disclosure interventions.
• Use the Transtheoretical model of behavior change to support improved health outcomes for MCC patients including treatment engagement and retention, medication adherence, risk reduction, and health provider communication.
• Maintain ongoing contact with MCC patients and monitor progress related to goals set in the individual care plan.
• Coordinate and communicate among members of the MCC patient’s care team including medical providers, mental health/addiction providers, allied health, community resources, and other MCC team members. Participate in interdisciplinary case conferences for assigned MCC patients.
• Conduct MCC services in accordance with Medical Care Coordination guidelines published by the LA County Department of Public Health, Division of HIV and STD Programs as existing or amended.
• Screen, assess, and plan appropriate interventions to minimize patient risk of acquiring or transmitting sexually transmitted infections.
• 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. Knowledge of behavioral health issues and effective treatment modalities; HIV behavioral health issues; ability to perform differential diagnosis using the DSM-V; various theoretical orientations; treatment modalities; clinical techniques and interventions; treatment planning; biopsychosocial assessment; crisis intervention and reporting obligations; HIV risk reduction counseling; HIV Prevention strategies; reporting obligations and available community services and resources; motivational interviewing, theories of change and harm reduction methods.

Ability to:

Communicate effectively orally and in writing; organize work in an effective manner; work in a collaborative, interdisciplinary, fast paced environment; work effectively independently and as part of a team; communicate and relate to a variety of personalities, ethnicities, and sexual orientations; complete documentation in a comprehensive and timely fashion in accordance with APLA H&W policies.

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 driver’s license; proof of auto liability insurance; and have the use of a personal vehicle for work related purposes. COVID-19 and Booster or Medical/ Religious Exemption required.

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