Case Coordinator – Pathways Center

Under the supervision of the Director of DAC Services and Programs, the Case Coordinator performs a variety of coordination services to all patients engaged in any clinical discipline within the Pathways Center. The Case Coordinator complies with the standards of care management for HIV+ primary care patients and assists other patients based on patient-centered identified needs.

• 1.
• Perform an initial assessment and annual re-assessment for each client enrolling in the HIV primary care program.
• 2.
• Develop a service plan to address needs identified in the assessments.
• 3.
• Coordinate services to complete the items in the service plan.
• 4.
• Coordinate and sustain connection of patients with appropriate SBH resources including Health & Wellness, Population Health, Health Home, care management, other special programs, and community resources.
• 5.
• Provide supportive services, such as medication adherence and HIV prevention education, to patients enrolled in HIV primary care and HIV prevention programs.
• 6.
• Assist patients engaged in the Infectious Disease practice as requested by the Infectious Disease Specialist 7.
• Coordinate outreach to encourage patient engagement in care and to help close relevant care gaps in a timely manner in the HIV primary care, HIV prevention, and Infectious Disease programs.
• 8.
• Collaborate with providers, case managers, social workers and others to ensure timely patient access to all required services or programs to address patient needs.
• 9.
• Facilitate intake for newly diagnosed HIV positive individuals in HIV primary care, whether through referral, escort to the program, or walk-in.
• 10.
• Accurately document all service related activities in the Center’s electronic health record.
• 11.
• Participate in program and/or departmental quality assurance activities as requested.
• 12.
• Perform any tasks assigned by the Program Director related to departmental activities as requested.
• 13.
• Attend scheduled department and division meetings and participate as appropriate.

Qualifications