Job Responsibilities
Responsible for the provision of a range of case management and outreach services to CBHC patients and families. Case management includes referral and linkage to primary and supportive care services, care planning, monitoring, crisis intervention, adherence counseling, and coordination of care and services with other care team members. Other responsibilities include community and clinic-based outreach; rapid infectious disease counseling, testing, and referral services; infectious disease education and prevention (PrEP), including screening and navigation; and linkage to medical care for new HIV patients. Typical patients are those presenting with complex needs and requiring moderately intensive monitoring and follow-up services.
MAJOR DUTIES AND RESPONSIBILITIES:
Problem Solving and Decision Making
- Thoroughly assesses needs and provides services to patients and their families to resolve problems which impact their physical and mental well being
- Assessing structural barriers to care in order to address and develop an action plan to eliminate such barriers
Patient Focus
- Counsels patients and families on a variety of community resources and assists with linkages
- Meets with patients on a regular basis to conduct and document psycho-social needs assessment
- Partners with clinicians to smoothly connect patients to medication assistance programs
Analytical and Critical Thinking
- Performs comprehensive intake assessments and completes all necessary documentation duties
- Provision of initial needs assessments and referrals for both newly diagnosed HIV positive patients, and those at high risk of HIV acquisition
Planning and Organizing
- Completes referrals in a timely and accurate manner
- Completes assigned triage and clinic duties in thorough, timely, and accurate manner
Teamwork
- Educates providers, the healthcare team, and the community about case management services
- Participate in internal and external HIV Testing/PrEP activities (special events as well as routine community activities)
- Coordinates presentations for community partners on health prevention topics
Workplace Computers and Equipment
- Maintains documentation that is legible and timely
- Completes monthly reports in a timely fashion
- Coordinates with other team members and Project Manager to maintain consistent testing supplies and datasheets
SKILLS AND ABILITIES:
- Knowledge of available community resources and ability to make effective referrals and follow up
- Decision making skills regarding priority setting and emergency situations
- Advanced psychosocial assessment and interviewing skills
- Supportive counseling skills and ability to work effectively with patients and families
- Ability to work with a diverse population
- Strong advocacy and organization skills
EDUCATION AND/OR EXPERIENCE:
- Required: High School Diploma and at least five years of related experience in health setting, community social work, case management, or outreach experience.
- Preferred: Bachelor's degree in social work, public health, human services or related field.
- Required: Certification in Testing, Linkage, and Care HIV testing course within 60 days of hire (training provided)