As part of this role, you will: Be responsiblefor day-to-day coordination of HIV patient medical care activities, including the entry of data and tracking of HIV services Identify patients for inclusion in the Program utilizing available metrics Perform comprehensive patient assessments upon entry to service and periodically, including patient and family support systems and needs, utilizing tools as required by funders Develop and implement an individualized patient care plan (that is goal-driven) with a focus on disease management and patient empowerment Assist patients and family with navigation of their health care system Monitor care plans and patients progress toward goal achievement; revise the plan as necessary, providing education and support as appropriate Provides problem-solving and case management services for patients (medical and social case management) under the supervision and direction of the Infectious Disease Supervisor Formulates problem-solving and case management plans in partnership with team members Monitors patients progress via the level of engagement in outpatient care and/or substance abuse programs, adherence to treatment plans, successful warm hand-offs to social service resources, and actual ability to access concrete supports Assists with linking and scheduling outpatient visits and follow-ups as needed. Assists patient in addressing and overcoming barriers with a range of concrete supports, including but not limited to healthcare support services, social work, financial assistance, child-care and caregiver support, housing, support with utility bills, food, financial entitlements, clothing, transportation, food pantries, violence prevention, social isolation, and any other appropriate community resources