Job Description

The Medical Case Manager at the Center for Key Populations (CKP) provides comprehensive, client-centered medical case management services to vulnerable key populations in New London County. This role focuses on coordinating care and ensuring timely linkage to healthcare services, including primary and HIV/Hep C care, behavioral health, dental care, substance use treatment, and other essential community resources.

Working within a multidisciplinary team, the Medical Case Manager partners closely with clients to promote treatment adherence, continuity of care, and engagement in services, with the overarching goal of achieving and maintaining viral suppression. The position carries a caseload of up to 50 traditional case management clients and is responsible for comprehensive service planning, goal setting, and ongoing monitoring.

Key Responsibilities:

Medical Case Management and Client Support:

• Provide medical case management services for up to 50 clients in accordance with RWB grant guidelines and HRSA/HAB standards of care.
• Conduct comprehensive client assessments to evaluate service needs, motivation, strengths, medication adherence, and understanding of HIV disease.
• Develop, implement, and manage individualized, comprehensive care plans in collaboration with clients and the multidisciplinary care team.
• Identify, address, and monitor barriers to medication adherence, treatment engagement, and retention in care.
• Maintain ongoing contact with clients through regular follow-up to support continuity and coordination of services.
• Provide ongoing, individualized patient education aligned with client goals and in coordination with PCP and HIV provider treatment plans.
• Maintain strong rapport with clients while promoting trust, respect, cultural humility, and confidentiality.

Administrative and Documentation Responsibilities:

• Provide administrative support to assigned sites- completing screenings to identify barriers to care, enrolling patients in all required systems, and maintaining accurate documentation. This includes demographic information, patient profiles, HIPAA forms, insurance cards, proof of income (for new and existing patients), sliding fee scale applications for uninsured patients, billing information, and pharmacy updates.
• Assist clients with services such as, but not limited to, scheduling primary and specialty care appointments, coordinating transportation, providing appointment reminders, completing referrals, and supporting follow-through on care plans.
• Work collaboratively with providers, case managers, peers, and administrative teams to ensure timely communication, coordination, and follow-up.

Grant Compliance, Documentation and Reporting:

• Monitor and implement the goals and objectives of the RWB grant to support overall project success.
• Maintain accurate, timely, and complete client documentation, including charts, encounter notes, and data entry into required systems.
• Complete triannual reports and other reports as requested by funders and leadership.
• Ensure documentation and service delivery meet funder, regulatory, and organizational requirements.

Community Engagement and Program Support:

• Establish and maintain strong working relationships with community partners to expand and strengthen available resources for clients.
• Assist with the implementation of project and program activities, including community events, outreach to community partners, service promotion, social media campaigns, research initiatives, and dissemination efforts.
• Actively participate in CKP staff meetings, program-specific meetings, quality management and quality improvement initiatives, and organizational and community meetings as directed by the supervisor.

Additional Responsibilities:

• Be available for evening and weekend work as required to meet client and program needs.
• Perform special assignments, projects, and other duties as assigned by the supervisor.

Qualifications:

Education & Experience

• Bachelor’s degree in Public Health, Human Services, Social Work, or a related field (preferred), or equivalent combination of education and experience in case management and/or HIV-related services.
• Experience providing client-centered service planning, care coordination, and medical or social case management.

Skills & Competencies

• Strong interpersonal, communication, and organizational skills.
• Ability to build and maintain effective working relationships with clients, providers, and community organizations.
• Proficiency with electronic health records (EHR) and documentation requirements.
• Ability to work effectively with diverse populations, including individuals with substance use disorders, mental health conditions, and those experiencing housing instability.
• Commitment to confidentiality, cultural humility, and trauma-informed care.

Additional Requirements

• Reliable transportation is required.
• Bilingual skills are preferred but not required.

PHYSICAL REQUIREMENTS/WORK ENVIRONMENT

At times, staff will enter organized and supportive housing environments and are required to climb up and down stairs. Most of the time, staff is expected to be in the office or at community agencies doing collateral work with or on behalf of the consumer. Community events are also a requirement of this position. Travel time by foot or automobile is required.

Confidentiality of Information

Confidentiality of business information is a requirement. Confidentiality must be maintained according to CHC policies.

Organization Information:

The Moses/Weitzman Health System is a global leader addressing challenges faced by organizations caring for the poor and diverse populations, and is home to programs focusing on education, research, and process improvement support for safety net providers. The system delivers primary care to more than 150,000 patients in Connecticut, and extends access to specialty care for more than 2.5 million individuals across the U.S. It is a national accrediting body for organizations training advanced practice providers, and offers accredited education and training for Medical Assistants in multiple states. As an incubator for new ideas in areas including social justice, the environment, and social determinants of health, the MWHS is addressing challenges faced by providers caring for underserved communities, creating innovative and impactful initiatives led by nationally and internationally recognized experts. As it forges pathways into the future of primary care, the MWHS honors Lillian Reba Moses (1924-2012), a granddaughter of slaves, and Gerard (Gerry) Weitzman (1938-1999), whose ancestors escaped pogroms in Eastern Europe. Their vision and commitment to justice and equity in healthcare is the foundation upon which the Moses/Weitzman Health System was built.

Location:

Community Health Center of New London

City:

New London

State:

Connecticut

Time Type:

Full time