Details

Provides community based outreach case management in coordination with physician. Provides assessment, intervention and stabilization of the individual’s medical and psychosocial care needs.

Conducts comprehensive assessments of the psychosocial, medical, financial, and supportive service needs of individuals newly diagnosed with HIV and other patients enrolled in HIV medical case management services.
Develops individualized treatment and service plans through collaboration with the patient, medical providers, and community services with the objective of successfully linking patients to HIV medical care, reducing barriers to treatment, increasing health system literacy, and promoting long-term engagement and retention in care.
Provides linkage to care services for individuals newly diagnosed with HIV, including coordination of initial medical appointments, assessment of barriers to care, facilitation of insurance and program enrollment, connection to supportive services, and ongoing follow-up to promote successful engagement and retention in HIV medical care.
Provides information and referrals for community resources to patients including, but not limited to, housing, transportation, financial assistance, food, clothing, legal services, mental health services, substance use treatment, and other supportive resources.
Assesses and discusses funding issues with patients, families, and healthcare providers to enhance cost-effective utilization of services and quality of care, while negotiating with third-party entities to obtain authorization for services and access to benefits.
Assists patients in obtaining and maintaining access to HIV-related services including medical care, medications, insurance coverage, Ryan White services, pharmaceutical assistance programs, and other community resources necessary to support successful treatment outcomes.
Monitors quality of care and provides advocacy to patients to ensure treatment plan goals are appropriate, understood, and implemented. Routinely assesses patient response to services while measuring treatment plan effectiveness and necessity. Identifies patient needs, including those of an ethical and cultural nature, and ensures that they are addressed.
Provides education and support regarding HIV treatment, healthcare navigation, appointment adherence, insurance systems, medication access, and available community resources with the goal of developing the knowledge and skills needed for successful long-term self-management of HIV care.
Provides timely documentation in databases and patients’ medical records, including interactions, interventions, and community resource contacts, and communicates encounters to physicians and mid-level providers.
Regularly attends meetings with clinical and community care teams for consultation and coordination of treatment planning needs.
Manages care for a specific caseload of clients.

Problem solving. This position performs patient interactions in a confidential manner and provides community resource referrals on an emergent and ongoing basis. Critical thinking skills are utilized to determine the appropriate level of intervention and develop treatment plans that prioritize patient needs. Crisis intervention skills are utilized to assist individuals coping with traumatic situations and significant life changes, including a new HIV diagnosis.

This position develops knowledge of relevant community resource agencies and services for patient referral needs.

Knowledge of the medical and psychosocial issues affecting individuals living with HIV is required.

This job description is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of the employee assigned to the job.

Bachelor’s degree in human or social services or equivalency (one year of education can be substituted for two years of related work experience). Demonstrated human relations and effective communication skills also required.

Fluency in the Spanish language is preferred.

This position is patient-sensitive and must fulfill all associated requirements. We protect our patients, coworkers and community by requiring all patient-sensitive employees to be immunized according to CDC standards and hospital policy. Limited exemptions may be made for documented medical contraindications or religious beliefs that object to vaccinations.

Applicants must demonstrate the potential ability to perform the essential functions of the job as outlined in the position description.

Social work licensure, or Bachelor in Social Work, or Bachelor of Science in Nursing, or Bachelor in Health or Human Services strongly preferred. Experience working with high-acuity, complex patients including people suffering from chronic disease, mental illness, drug addiction and chronic homelessness. Reliable transportation. Fluency in Spanish.