About The Role

Ensures case coordination, effective use of resources and quality of care in accordance with the NYS AIDS Institute Standards of Care and HRSA Part D Standards of Family Case Management by performing the following duties.

Education and Experience

Bachelor’s degree in psychology, Sociology or Social work required, Master’s Degree preferred
Minimum of 1 year of documented experience in the provision of case management services to medically compromised patient population, familiarity with community resources, and ability to work as a member of al interdisciplinary medical team.

Essential Duties and Responsibilities include

Completion of initial Orientation (Center wide and specific HIV Medicine) and satisfactory completion of the HIV Competency Orientation Tool
Understanding and putting into practice hospital standards and division policies as it applies to employment at AMCH as well as the Division of HIV Medicine
Understanding and putting into the practice the HIV CM policies and procedures as designated in the Division of HIV Medicine Policy and Procedures
Yearly participating in the Competency Based Evaluation Process

Interviewing/Assessment

Conducts age-appropriate interviewing with clients identifying problems such as adjustment to illness, employment, food, clothing, housing, substance abuse, and physical and mental impairments to determine nature and degree of problem.
Secures information such as medical, psychological, and social factors contributing to client's situation, as well as their annual income, and evaluates these in the context of the client's capacities.
Assesses persons in crisis and provides intervention, keeping self and client safety as principal objective of contract, with an understanding of legal responsibilities in cases of domestic violence and abuse issues.

Supportive Counseling/ Intervention

Age appropriately counsel’s client individually and /or with significant social supports regarding plans for meeting needs, aids the client to mobilize inner strengths and works cooperatively with community resources to improve overall functioning and independence.
Counsel’s patients in adjustment to life threatening illness and its implications, acknowledging issues of diversity and adjusting intervention and practice accordingly.
Understands legal issues around domestic violence and abuse issues and intervenes appropriately and in accordance with Albany Medical Center’s policy and NYS law.

Case Coordination/ Interdisciplinary teamwork

Maintains a Part D caseload and develops a system or tool to remain organized and track patients on caseload.
Prepares client assessments, service plans and encounter reports. Documents patient encounters and care coordination efforts in a clear and concise manner, concentrating on facts and justifying all impressions with objective information.
Completes semi annual re-assessments on Part D patients, reviews medical and psychosocial information from patient report and available records and evaluates these in the context of the client's capacities.
Develops and reviews semi annual service plans with patient, revising plan according to patient input or changes in patient needs
Works in close collaboration with physicians and other health personnel in client evaluation and treatment to further their understanding of significant social and emotional factors underlying client's health problem.
Track and follow patient Medication refills with Pharmacies monthly.
Facilitates formal case conferences, as needed, to provide coordinated services to the patient.
Assess health literacy, and assist patients in understanding medical recommendations, as needed.
Initiation of Advance Directives as appropriate
Screens client for eligibility for entitlement programs and refers client to appropriate services/agencies. Refers clients to other community resources and other organizations based on identified needs.
Accesses and records client and community resource information.

Patient Education

Helps client to modify attitudes and patterns of behavior by increasing understanding of the HIV disease process and transmission factors.
Discusses HIV transmission and partner notification with client. Utilizes motivational interviewing techniques to facilitate behavior change, as needed.
Provides coverage for walk- in HIV counseling and testing, as needed.
Educates clients on the availability of clinical trials.

Other duties

Represents AIDS Program in the community through tasks forces, community forums, and boards as assigned.
Upkeep of educational record and ongoing continuing education for personal, professional, and program development
Participation in ongoing supervision for continued professional growth.
Participates in quality improvement projects.
Other duties may be assigned.

Thank you for your interest in Albany Med Health System!

Albany Med Health System is an equal opportunity employer.

This role may require access to information considered sensitive to Albany Med Health System, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that:

Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Health System policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.