Overview Join to apply for the Linkage to Care Coordinator role at Vivent Health .
The Linkage to Care Coordinator provides intensive care coordination, support and services to HIV-positive individuals who require rigorous assistance to improve their ability to access and remain in care. This role coordinates with HIV testing sites as needed to initiate access to care, works with clinical staff to promote adherence to medical, behavioral, oral health and pharmaceutical care; provides treatment education; collaborates with other programs within Vivent Health and with local providers; and offers direct interventions to reduce barriers to care for the benefit of patients. The position also educates HIV-positive individuals on the importance of HIV medical care and empowers them to navigate medical and social systems on their own.
Essential Functions
Provide highly focused, intensive, time-limited support to persons newly diagnosed with HIV disease, persons from corrections facilities 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 at 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 to persons with HIV infection, including: assessments/reassessments, service planning, and coordination of services and/or service plan monitoring.
Collaborate with community physicians, nurse practitioners, therapists, dentists, pharmacists, and other case managers to identify patient health needs and ensure accessible, confidential, high-quality services.
Develop and implement a health care plan with patients to meet their needs and retain them in care; help patients become self-advocates and navigate health and social systems.
Assess benefits and insurance; assist with access to 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.
Make appropriate referrals for services needed to stabilize patients in care and follow up to ensure service delivery.
Accompany patients to health appointments; may include transportation to and from appointments as directed by supervision.
Provide a high level of service with substantial time spent in the community, at patient homes, and other locations to meet patient needs; support increased health literacy and self-management skills.
Contribute as an active team member in the Social Services Department; participate in meetings, trainings, planning activities, and provide support and training to coworkers as needed.
Collaborate with Medical, Dental, Pharmacy, and Behavioral Health teams to ensure timely access to care and adherence to treatment plans.
Establish working relationships with community resources providing HIV testing and related health, mental health, and social services to underserved populations.
Maintain patient files and timely documentation using electronic case management systems (SCOUT) and/or Epic.
Maintain knowledge of HIV/AIDS, treatment options, risk reduction, chronic diseases, mental health, and case management through ongoing self-study and training.
Participate in rotating on-call coverage; some evenings and weekends may be required.
All other duties as assigned.
Qualifications
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 activities, conducting screenings, 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, medical appointments, etc.
Knowledge of and sensitivity to the HIV/AIDS patient population, and/or willingness to learn about this community.
Extensive knowledge of medical, social and mental health delivery systems.
Extensive knowledge of HIV disease, treatment options, and related issues.
Strong written and verbal communication skills; client-centered communication and assessment skills.
Ability to build relationships with culturally diverse populations.
Strong organizational skills with the ability to manage time and keep clear records.
Working knowledge of Spanish is a plus.
Salary
Starting at $49,920/year (Depending on Experience).
Public Student Loan Forgiveness
Employment at our organization may qualify you for federal student loan forgiveness programs. We do not directly pay for or 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 qualification.
Please review one such program and its requirements at: https://studentaid.gov/manage-loans/forgiveness-cancellation/public-service