Registered Nurse Case Manager (Ryan White)

Marin Community Clinics, founded in 1972, is today, a multi-clinic network with a wide array of integrated primary care, dental, behavioral, specialty and referral services. As a Federally Qualified Health Center (FQHC), we provide vital health services to almost 40,000 individuals annually in Marin County. The Clinics regularly receive national awards from the Health Resources and Services Administrations (HRSA). Our Mission is to promote health and wellness through excellent, compassionate care for all. 

Marin Community Clinics is looking for a mission-driven Ryan White RN Case Manager to join our dynamic, multidisciplinary, Specialty Clinic Care team to advance our goal of improving health outcomes for people living with HIV/AIDS (PLWHA).  Our Specialty Clinic team is committed to increasing health equity among Marin’s most vulnerable patients through person-centered, trauma-informed, case management support.  Working collaboratively with primary care, specialty care, oral health care services (dental), behavioral health, and other members of the clinical care team, Ryan White RN Case Manager works as a member of an expert team of professionals to provide patient-centered, outcome- driven care that promotes independence and dignity.

To this end, The Ryan White RN Case Manager will work within the Infectious Diseases team to provide comprehensive eligibility assessments, outreach and engagement, care planning, and administrative coordination, with the goal of supporting a panel of people living with HIV (PLWH) by identifying and minimizing barriers to care, improving health outcomes, and helping patients increase capacity to manage their needs with greater independence.  The Ryan White RN Case Manager role is a patient-facing role that aims to engage patients in care by acting as liaison to the larger care team and takes initiative and plays a leadership role in the direction and implementation of the Ryan White program.  The RN Case Manager will report to the Clinic Manager. 

• Understands the interplay between chronic conditions and psychosocial issues; 
• Is comfortable working with individuals with complex behavioral and/or physical health presentations and/or substance use disorders;
• Provides nurse education for acute and chronic illnesses and triage any issues concerns as needed;
• Assesses and refills medications per MCC protocols;
• Provides case management support to individuals eligible for Ryan White case management as well as to other PLWH in adherence with Ryan White program requirements ;
• Maintains knowledge of community resources,  including housing resources, and is able to facilitate connections of patients to these resources;
• Assesses for eligibility and monthly distribution of food cards.  Maintains accurate monthly reporting of food card distribution;
• Initiates outreach and engagement of target population. Assists patients with completion of necessary forms and applications in compliance with the Ryan White program;
• Works with patients to address social determinants of health (SDOH);
• Tracks referrals and provides follow-up to ensure service delivery;
• Provides administrative support including records retrieval and review, eligibility screening, goal tracking;
• Conducts home/community visits as needed;
• Consults and coordinates with interdisciplinary care team, including Medical Director and other Medical Providers, behavioral health, care navigation MAs, nursing, and external partners;
• Documents all patient interactions and services using MCC’s electronic health record AND secondary database;
• Attends internal and external meetings (i.e. case conferencing, administrative);
• Attends trainings as needed in areas which may include health coaching, engagement techniques, etc;
• Builds partnerships with stakeholders such as Marin County and Community Based Organizations (CBOs);
• Produces timely and accurate reporting of data as requested by the MCC Ryan White Program.
• Ensures all contract and reporting requirements are met
• May travel between clinics or meet patients in the community as needed;
• Provides frank and considered opinions regarding case management services and quality improvement measures;
• May be asked to work variable schedule during extended-hour clinics (e.g., 10am-7pm on one or more days).
• Works closely with other members of the Infectious Disease team to update and review patient lists, including but not limited to food card list and master line list;
• Works with the Quality Department to create and implement workflows in order to meet Ryan White requirements;
• Proficiently uses ARIES to document labs, office visits, and other aspects of case management;
• Covers for the Infectious Disease RN in their absence;
• Assists the Infectious Disease RN with nursing responsibilities as needed;
• Other duties assigned.

Education and Experience:

• Nursing Degree from accredited School of Nursing
• Active California RN License in good standing;
• CPR Training Current;
• Valid Driver’s License;
• Bilingual in Spanish desired;
• Experience (and passion for) providing support to individuals living with HIV/AIDS highly desired;
• Experience/familiarity with housing resources/housing navigation in Marin highly preferable;
• Knowledge of state regulations and legal/ethical standards related to patient rights, and client/patient confidentiality required;
• Experience with Ryan White Care Act highly desired;
• Training in motivational interviewing highly desired/or willingness to learn;
• Experience with EPIC Electronic Health Records preferred.

Required Skills and Abilities

• Must be fluent in English with the ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports and business correspondence in English
• Must be able to communicate with patients and partners in Spanish: effectively present information and respond to questions from clients, customers, and the general public in Spanish. Strong preference for a candidate that is able to conduct clinical assessment interviews and case management interventions with patients in Spanish.
• To perform this job successfully, an individual must be computer literate and knowledgeable in Microsoft Office software programs

Physical Requirements

• Prolonged standing and walking
• Prolonged periods of sitting at a desk and working on a computer
• Must be able to lift up to 15 pounds at times

Benefits Information:

Hiring Bonus: $1,000.00

Relocation Assistance: NA

Our benefits program is designed to protect your health, family and way of life. We offer a competitive Benefits Program that includes affordable health insurance and Health Reimbursement Accounts (HRA), Dental and Vision Insurance, Educational and Continuing Education Benefits, Student Loan Repayment and Loan Forgiveness, Retirement Plan, Group Life and AD&D Insurance, Short term and Long Term Disability benefits, Professional Fee Reimbursement, Mileage and Cell Phone Reimbursement, Scrubs Reimbursement, Loupes Reimbursement, Employee Assistance Programs, Paid Holidays, Personal Days of Celebration, Paid time off, and Extended Illness Benefits.

MCC is an equal opportunity employer.  We enthusiastically accept our responsibility to make employment decisions without regard to race, religious creed, color, age, sex, sexual orientation, gender identity, national origin, religion, marital status, medical condition, disability, military service, pregnancy, childbirth and related medical conditions, or any other classification protected by federal, state, and local laws and ordinances.