To provide strengths-based Case Management services to persons living with HIV/AIDS. Facilitates and monitors client service acquisition and progress with the goal of successful engagement in comprehensive HIV Care.
· Bachelor’s degree in Social Work, R.N., B.S.N., or 2 years’ experience in Case Management type services; less than 3 years’ post graduate experience in Case Management type services or
· Master’s degree in Social Work, Nursing, or related field, with less than 2 years’ post graduate experience
· HIV/AIDS, hepatitis, and substance abuse prevention or service coordination experience with the target population preferred;
· Demonstrated experience serving a diverse population;
· Possess clinical problem solving and critical thinking skill
Client Assessment, Service Planning, Care Coordination, and Customer Service
· Compiles comprehensive client assessments in order to develop and asses the efficacy of an HIV focused plan of care (goal/service plan);
· Evaluates the client’s eligibility for government funded programs (i.e. Medicaid, Medicare, Social Security etc.), and provides referrals and follow up as appropriate;
· Participates in client progress review, community placement, follow-up services, and discharge planning by participating on the Clinic’s HIV Multidisciplinary Team and/or with other community based organizations or medical providers as necessary;
· Provides ongoing client referrals to appropriate community resources and services based on client need and eligibility. Confers with said referrals (medical facilities, schools, community groups, public health, social service agencies, and other service providers) to discuss client referrals, follow-up care, decisions affecting the client, and to explain agency policies, treatment philosophy, and programs; when sharing client information, maintain HIPAA and client confidentiality standards;
· Maintains regular contact with clients to provide ongoing assessment, support, intervention and satisfaction of services. As this is a short-term intensive case management program, contact will be made weekly for the first 6 weeks of engagement in Linkage to Care then contact will gradually disengage to one time per month. This includes timely follow-up with client plan of care (goal/service plan) as documented in client file (SCOUT Service Plan);
Client Education, Access to Health Coverage, and Advocacy
· Provides education to clients on HIV, medication and medical appointment adherence, viral load and CD4 lab results, and risk reduction strategies; provides specific education to specialty clients (newly diagnosed or returning to medical care) regarding: coping and acceptance of new diagnosis, navigation of health care system, and HIV education
· Enrolls/makes referrals for clients to enroll in the most comprehensive insurance plan available to them (Medicaid, Medicare, Marketplace Plan, Off-Marketplace plan, COBRA, etc); assesses client eligibility for insurance premium and co-pay assistance; educates clients on process for submitting insurance and co-pay documentation; and works closely with client and necessary third-parties (including insurance companies) to maintain insurance coverage;
· Serves as client advocate to ensure access to, and understanding of, needed services; this may include assisting clients in applying for government funded programs, connecting clients to legal resources, serving as client reference for service applications; and attending medical appointments routinely to ensure client understanding of medical care and treatment regimen
Data and Quality Management
· Maintains professional, well written, comprehensive, and accurate client record, documenting interactions with clients and/or on behalf of clients and according to program standards (SCOUT database);
· Completes program reports and data requests in an accurate, thorough, timely manner (including, but not limited to, monthly program reports, and data requests from regional and state levels)
· Participates in quality improvement projects as requested, including researching client data/trends, utilizing data measures to prioritize client contact, and assisting in streamlining internal procedures
HIV Case Management Team Support; and Clinic and Community Involvement
· Performs “on-call” duties and acts as team leader on scheduled days including weekends and after end of business day (i.e. responding in person to testing site when available when paged for new diagnosis or return to care, providing education and support to clients upon page, triaging needs of presenting client and testing site, attending to client needs after business hours when paged);
· Attends scheduled Kansas City Health Department Ryan White Title I/Title II HIV Case Management meetings and other internal team meetings as scheduled by the program supervisor; and attends Comprehensive HIV Prevention and Care Planning Council monthly meetings on a rotating team schedule
· Participates in community outreach events including counseling and testing, overview of Linkage to Care Program, and educational needs as requested. Events may include evening and weekend hours.
· Supports the mission and vision of the KC CARE Health Center;
· Operates as a team member of the KC CARE Health Center; supporting other staff members when needed;
· All duties as assigned by Department Director or Senior Staff Members when required for the smooth operation of the Clinic and/or its Administrative functions. Perform other duties as assigned that are related to HIV continuum of care programming;
Physical Demands/Working Conditions:
· Intermittent physical activity including walking, standing, sitting, stooping, lifting boxes and files under 25 pounds and lifting.
· Potential exposure to virus, disease and infection from patients in working environment.
· May be required to work extended periods based on business need.
The above information is intended to describe the most important aspects of the job. This job description is not intended to be construed as an exhaustive list of all responsibilities, duties and skills required in order to perform the work. Duties, responsibilities and activities may change at any time with or without notice. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job. The KC CARE Health Center is committed to providing equal employment opportunity/affirmative action (EEO/AA) to all job applicants and employees