Duties and Responsibilities include but are not limited to:
Specific timelines outlined in this job description are contractual and/or regulatory in nature, and therefore are subject to change when Medicare or Medi-Cal contracts, guidelines, laws and/or regulations are changed or modified.
- Maintains comprehensive knowledge of AHF Model of Care (MOC) Leads assigned Model of Care-Care Management Team.
- Completes Medicare Plan assessments, re-assessments and care coordination for members assigned within 90 days of enrollment for initial assessments and within 364 days for reassessments. Assures member is seen by his/her Primary Care Provider (PCP) within 90 days of enrollment.
- Completes Medi-Cal Plan assessment within 120 days of enrollment, annual reassessments within 364 days and assures member is seen by his/her PCP for a first Initial Health Assessment visit within 120 days of enrollment in accordance with the MMCD Policy Letter 08-003.
- A Comprehensive Medication Review of all Medicare Members within 60 days of enrollment and quarterly Medication Therapy Management reviews per AHF policies.
- Maintains current knowledge of medications used by member population and educates member on reasons for use, proper dosing, special considerations, side effects, contraindications, etc.
- Collaborates with Plan Pharmacist when medication issues are identified.
- Informs prescribing providers when issues are identified and requests interventions when appropriate.
- Reports all complaints and grievances per grievance policy.
- A Comprehensive Medication Review of all MediCal Members within 120 days of enrollment and quarterly Medication Therapy Management reviews per AHF policies.
- With the member, establishes patient centered, long-term and short-term goals in an Individual Care Plans to be completed at time initial assessment, and updated, at a minimum, according to stratification severity level per AHF policies. Care plans will reflect the medical diagnosis and psycho-social needs of the member and will be shared with member’s provider.
- Collaborates with Model of Care Team to execute the member individualized care plan, maintain contacts related to acuity level, and assure continuing engagement in care.
- Documents all activities in the Care Management System. Documentation in medical provider is not the primay source of documentation for the Care Management process, however the RNCTM may send Care Management documents to the provider for inclusion in the provider EMR.
- As an embedded care manager at their assigned HCC, the RNCTM collaborates with and plays a lead role in assuring providers and staff have the most comprehensive understanding of assigned plan members’ needs. Assessment progress notes and pertinent information will be entered in Case Management Notes within the EMR as part of that collaboration. Conducts Model of Care Welcome calls with all new members.
- Meets with Model of Care Team to oversee MOC activities and assure delegated activities have been executed.
- Reviews member claims at least monthly.
- Follows up on all ER visits to identify issues and where possible prevent recurrence. Documents interventions post ER follow-up.
- Monitors each members adherence to preventive health activities and works with member to achieve adherence to preventive health interventions, e.g., yearly flu vaccination, colo-rectal screening, PAP smear, mammography, pneumococcal vaccination, eye examinations, dental check-ups, etc.
- The RNCTM will maintain current knowledge of plan benefit structure, policies and procedures related to authorization of services; and is adept at creating a wrap around solution to address member’s needs in collaboration with the authorization department, HCC staff and available ASO and community resources.
- When appropriate, the RNCTM will collaborate with external network PCPs, the Care Team and other practitioners to ensure members are well supported and managed within the Health Home of the Chronic Care Model.
- An understanding of Risk Adjustment so that collaboration with the HCC provider results in the most appropriate risk score for members.
- Works to deliver care management services in an efficient and cost effective manner, by analyzes medical records and claims and applies medical necessity criteria and benefit plan requirements to determine the appropriateness of benefit requests
- Reviews member status on a continual basis for any change in condition, including ER admission, hospitalization admission, SNF placement, outpatient services, high utilization, high risk medication and polypharmacy and collaborates with provider. Works with member to stabilize health condition, improve health and improve indicated and appropriate usage of health care resources.
- Performs home visits for assessments, care planning, home safety evaluations, etc. as necessary.
- Works to re-engage the members appearing on the “104 day” or “35 day” report or any non-adherent or lost-to-care scenario. Documents activities in Care Management System.
- Monitors the appropriate use of outpatient ancillary services, medication adherence, compliance to PCP visit schedules and results of lab work. Intervenes to improve when issues are identified.
- Provides support to patient in the form of calls, follow-up visits, collaboration with providers and family in all care settings. Documents all contacts in Care Management System.
- Provides health education regarding disease process, medications, medication adherence, community resources and benefits. Documents such encounters in Care Management System.
- Collaborates with AIDS Service Organizations and other community resources, as necessary, to ensure appropriate access to care and services.
- Maintains current clinical knowledge of HIV/AIDS medications and treatment regimens.
- Maintains at least the minimum performance and productivity standards as outlined by management, participates in weekly productivity review with management. .
- Completes a minimum of three recommended AIDS related in-services, trainings or conferences per year.
- Reports urgent member issues and barriers to care to the Primary Care Provider and the Manager or Director of Care Coordination, as appropriate.
- Advocates for member needs with medical provider in all care settings,
- Obtains and maintains HIV/AIDS disease/treatment general knowledge proficiency
- Other duties as assigned to ensure team goals are met.
Coordinates Model of Care Team, i.e., Social Worker, LVN Care Partner, Care Coordinator, in the delivery of Model of Care services to members. Evaluates such performance and provides feedback to CM Manager on Team performance.
Participates in team conferences during weekly Interdisciplinary Team Rounds.
Collaborates with the Plan Medical Director, Manager and Director of Care Coordination on member adherence, clinical status, satisfaction, utilization and cost issues.
We at AIDS Healthcare Foundation believe that each individual is entitled to equal employment opportunities without regard to race, color, creed, gender, sexual orientation, gender identity, marital status, national origin, age, veteran status or disability. The right of equal employment opportunity extends to recruiting, hiring selection, transfer, promotion, training and all other conditions of employment.