Rutgers, New Jersey Medical School, Department of Medicine – Division of Infectious Disease, seeks a highly motivated Senior Care Coordination Specialist! This position will focus on coordinating services for transgender and high risk/high acuity patients with untreated mental, emotional or substance abuse problems. The Senior Care Coordination Specialist will work as the Licensed Social Work Medical Case Manager (LSWMCM) and contribute to the success of the program through the achievement of high quality care management delivery and positive clinical outcomes, while meeting the administrative and contractual performance targets, documentation standards, and billing requirements of the grant program(s). The LSWMCM is responsible for meeting the HRSA standards for medical case management that include (1) initial assessment of service needs; (2) development of a comprehensive, individualized service plan; (3) coordination of services required to implement the plan; (4) client monitoring to assess the efficacy of the plan; and (5) periodic re-evaluation and adaptation of the plan as necessary, as well as patient specific health education, monitoring, assessment, and deployment of techniques to assure the engagement and retention in care. The Senior Care Coordination Specialist is also responsible for advocacy, treatment adherence monitoring, coordination of services to access medically appropriate levels of mental health, substance abuse and other support services, and ensuring that HIV and other chronic illness outcome measures are addressed.
Assesses patients (with an emphasis on clinic patients presenting with gender dysphoria) and works collaboratively with the patients, their medical provider, designated family/significant others, and community support service providers to address the needs identified in the patient's health and psychosocial risk assessment and implement a plan of care based upon the needs identified.
Educates/counsels clients in individual and group sessions to assist them in dealing with substance abuse, mental and physical illness, poverty, unemployment, or physical abuse.
Facilitates the development and implementation of a comprehensive, multi-disciplinary plan of care for patients with complex mental health and/or substance abuse and socio-economic problems, in collaboration with the physician and other members of the healthcare team.
Develops a Plan of Care (POC) based upon the health and needs assessment at time of intake and to follow the service delivery guidelines for follow-up care and reassessments based upon the clients acuity scale.
Coordinates the activities of physicians, clinical staff, patients and families and other agencies to ensure optimal patient outcomes.
Coordinates care planning, the identification of referral sources, provides referrals and follow-up, eligibility screening, and participates in activities that increase understanding of the communities.
Monitors and coordinates hospital, emergency room, medical sub-specialty treatment plan recommendations, outpatient and ancillary services, lab values in order to improve program effectiveness.
Collaborates with AIDS Service Organizations (ASOs) and other community services in the Eligible Metropolitan Area (EMA), including specialty care providers, as necessary to ensure appropriate access to services and follow- up on the results to such referrals.
Assists in the coordination and monitoring of the unit's buprenorphine program. Follows all guidelines and standards regarding record keeping and documentation.
Minimum Education and Experience:
Licensed Social Worker (LSW/LCSW) with a license to practice in the State of New Jersey.
Master's degree in Social Work (MSW) from a professional school accredited by the Council of Social work plus two (2) years post MSW experience.
Patient experience in the area of mental health and/or substance abuse required.
At least 2 years of clinical experience in the care of people with HIV/AIDS.
Minimum one year managed care and/or case management experience required.
Required Knowledge, Skills, and Abilities:
Computer literacy with competence in Microsoft Office components.
Detail oriented with excellent organizational and communication skills.
Excellent written and verbal communication skills.
Excellent organizational skills.
Previous experience working with the transgender community.
Knowledge of ICD10 coding is a plus.
Physical Demands and Work Environment:
PHYSICALDEMANDS: Position requires standing to 1/3 of the time, walking to 2/3 of the time, requires sitting 1/2 of the time, talk or hear over 2/3 of the time. There are no special vision requirements.
Posting Number: 18ST0979
Location: Newark (RBHS)
Internal Number: 62230
About Rutgers University
Rutgers, The State University of New Jersey, is a leading national public research university and the state's preeminent, comprehensive public institution of higher education. Rutgers is dedicated to teaching that meets the highest standards of excellence; to conducting research that breaks new ground; and to turning knowledge into solutions for local, national, and global communities. As it was at our founding in 1766, the heart of our mission is preparing students to become productive members of society and good citizens of the world. Rutgers teaches across the full educational spectrum: preschool to precollege; undergraduate to graduate and postdoctoral; and continuing education for professional and personal advancement. Rutgers is New Jersey's land-grant institution and one of the nation's foremost research universities, and as such, we educate, make discoveries, serve as an engine of economic growth, and generate ideas for improving people's lives.