Linkage to Care Coordinator

Our expectations

• Winning skills and behaviors for success
• Provide highly focused, intensive, time-limited support to persons newly diagnosed with HIV disease, persons from corrections facilities who are returning to the community (if applicable), persons at high risk for falling out of care, or who have lapsed from care.
• Conduct immediate response for newly diagnosed clients in clinic or outside testing partner agencies as assigned.
• Complete intake and other screenings to identify barriers to care and, with the patient, devise possible solutions that are effective and sustainable.
• Provide case management services, according to the state HIV Medical Case Management Standards, to persons with HIV infection through;
• Assessments/Reassessments;
• Service Planning;
• Coordination of Services and/or Service Plan monitoring;
• Work with appropriate community physicians, nurse practitioners, therapists, dentists, pharmacists, and case managers to identify patient health needs and to ensure accessible, confidential, and high-quality services to patients.
• Work with patient and providers to develop and implement a health care plan to meet patient needs and retain patient in care. This plan will include objectives that will facilitate the client in becoming a good self- health advocate and developing skills needed to navigate necessary health and social delivery systems.
• Assess benefits and insurance, and if needed, provide assistance to access payor programs. Enroll in Vivent Health’s Medical Home if applicable.
• Facilitate communication among the care team.
• Provide HIV disease prevention and treatment adherence education.
• Assist with making appropriate referrals for services needed to stabilize patient in care and follow-up to ensure service delivery.
• Accompany patients to health appointments; in consultation with the supervisor, this may include transportation to and from and attendance at the appointment.
• Provide a level of service that is highly intensive. This involves large amounts of time in the community, at patient homes and in other locations that meet the patient’s needs best. This intensive service is to aid the client in becoming more ready for Community or Clinic case management services and to increase their health literacy and self-management skills.
• Contribute as an active member of the Social Services Department by participating in staff meetings, in-service trainings and workshops, department or agency planning activities, assisting with special projects, and providing support, peer mentoring and training to co-workers as needed. Provide feedback about best practice standards, program improvement, and unmet patient needs.
• Collaborate extensively with Vivent Health’s Medical, Dental, Pharmacy, and Behavioral Health Clinics personnel to ensure that clients obtain appropriate and timely access to all needed care, and to maximize adherence to medical treatment plans.
• Through outreach, education, and collaboration, establish a working relationship with appropriate community resources in the area, including those providing HIV testing and/or health, mental health and social services to underserved and target populations.
• Maintain appropriate patient files and timely documentation of services utilizing electronic case management (SCOUT) and/or medical software such EPIC.
• Update and maintain a strong working knowledge of HIV/AIDS, treatment options, risk reduction techniques, chronic diseases, mental health issues, case management, and other related issues through self-study and participation in trainings, workshops, and in-services and in consultation with supervisor.
• Collaborates as team member to achieve organizational and department goals including participation in rotating on call coverage. Some evenings and weekends required.
• All other duties as assigned.
• Adherence to all agency policies, including Confidentiality, Employee Handbook, Health Care Corporate Compliance Plan, Standards of Conduct, and other relevant policies.

NOTE

Reasonable accommodation may be made to enable individuals with disabilities to perform essential functions.

Knowledge required

• Required and preferred knowledge and experiences to succeed.
• Bachelor's degree in social work, health care, or a human service discipline from an accredited college or university is required.
• 2+ years' experience in outreach-type activities, conducting screening, providing education and/or direct services in a community-based health clinic or social service environment.
• Must have a valid driver’s license.
• Local Travel for Home/Community Visits, Med Appts, etc.
• Knowledge of and sensitivity to the HIV/AIDS patient population, and/or an eagerness to learn about this community.
• Extensive knowledge of medical, social and mental health delivery systems.
• Extensive knowledge of HIV disease and related issues, disease progression, and treatment options.
• Demonstrated effective written and verbal communication skills, including client-centered communication and assessment skills.
• Ability to establish and maintain effective public and working relationships with culturally diverse populations from a wide range of life circumstances and backgrounds.
• Ability to effectively organize work products and files, keep clear records, and manage time well so as to optimize efficiency and productivity.
• Working knowledge of Spanish language (bilingual) is a plus.

Additional

Preferred Qualifications

• HIV experience in a not-for-profit environment.

Statement of inclusion

Vivent Health is an equal opportunity employer and will recruit, hire, promote, and transfer qualified persons into all job classifications regardless of race, gender, religion, skin color, national origin or ancestry, physical disability (including pregnancy), mental disability, age, gender identity, sexual orientation, legally protected medical condition, family care status, marital status, veteran status, genetic characteristics, or any other characteristic protected by federal or state law. Vivent Health complies with other expanded protected classifications that specific county or municipal regulations may mandate.

Vivent Health is deeply committed to fostering respect, dignity, and understanding for all individuals affected by HIV, regardless of race, ethnicity, sexual orientation, gender identity, socioeconomic status, or any other characteristic. We are dedicated to cultivating a supportive and inclusive environment that champions advocacy, education, and compassionate care for everyone in our diverse community.

Going beyond the law’s requirements, Vivent Health places great importance on fostering a culture that celebrates diversity, equity, inclusion, and belonging. We actively seek qualified candidates from different racial, cultural, and economic backgrounds, as we believe that differing perspectives and experiences make us stronger as an organization. Vivent Health encourages all interested persons to apply for this position, and we look forward to learning more about your unique background and qualifications.

As a recipient of federal funding, Vivent Health will not hire nor enter a contractual relationship with any party debarred, suspended, or excluded from federal assistance programs.

Salary: Starting at $50,000/annually (Depending on Experience)

The final salary will be determined based on factors such as market data, internal equity, candidate experience and qualifications. Please note that it is uncommon for an individual to be hired at or near the top of the range.

Public Student Loan Forgiveness

Employment at our organization may qualify you for federal student loan forgiveness programs. We do not directly pay for – nor forgive – federal student loans; however, our status as a not-for-profit organization under Section 501 (c) (3), makes us an eligible employer. There may be other determining factors for one to qualify.

Please follow this URL to review one such program and their requirements

https://studentaid.gov/manage-loans/forgiveness-cancellation/public-service [https://studentaid.gov/manage-loans/forgiveness-cancellation/public-service]