The Case Manager will provide comprehensive individualized case management services to people living with HIV (PLWH) in Alameda County. It is the responsibility of the HIV Case Manager to provide: a wide spectrum of services as a part of a primary care team; help to improve the health and well-being of our primary care patients and promote team functioning; and provide clinically and culturally sensitive outreach services to marginally housed adults in order to engage them in primary care services. Interventions may include crisis intervention, brief behavioral interventions, psychosocial assessments, collaboration with outside service providers, and appropriate internal/external referrals. Strong attention to detail as well as above-average interpersonal and organizational skills are necessary for the position. The position will require travel to sites throughout Alameda County.
This position is represented by SEIU-UHW. Salaries and benefits are set by a collective bargaining agreement (CBA), and an employee in this position must remain a member in good standing of SEIU-UHW, as defined in the CBA.
Care coordination
Primary Care coordination
Help retain PLWH in care at the East Oakland Health Center. This includes reengaging patients who have had a lapse in medical care.
Coordinates health care for individuals in need of assistance with adherence to medication. The goal is to help all PLWH to maintain an undetectable viral load. Assists with medication reconciliation.
Links newly identified PLWH to available social services, including legal, housing, transportation, mental health, substance abuse, and pain management services.
Tracks client follow up and care plan outcomes. Coordinates with medical providers regarding need for enhanced services.
Documents client progress, referrals, encounters, services, and treatment progress in the centralized client management system to allow appropriate sharing with others program service providers.
Assists with patients navigating barriers to care, treatment and social support:
Assists patients in navigating the requirements of medical insurance.
Enrolls patients in AIDS Drug Assistance Program.
Eligibility determination to ensure access to community services.
Tracks, manages, and facilitates specialty referrals to ensure patients are successfully linked to services.
Makes appointments and completes reminder calls for primary care provider panel.
Documentation
Enters all encounters and units of service into the electronic medical record Epic, ARIES, and other data management systems as required.
Maintains documentation of services to allow compliance with required reporting.
Maintains strict adherence to all program requirements and deadlines including report deadlines and timely completeness of documentation for site visits and audits.
Health coaching (patient self-management support)
Coaches PLWH in self-management (e.g. medication adherence, lifestyle) including self-care skills.
Assists patients in developing and executing health-related action plans or behavior changes based on client goals.
Navigates problem-solving with patients as they encounter obstacles to achieving health-related goals.
Conducts brief interventions with patients regarding alcohol and tobacco use and other behavioral health issues as appropriate.
Agency and clinic meetings
Participates in weekly case conferences with the HIV-Access team and monthly HIV Care and Prevention team meetings.
Represents the HIV Access Program at regular meetings of the Alameda County Office of AIDS and the HIV Access division of the Community Health Consortium Network.
Coordinates with other clinics within Lifelong Medical Care and across Alameda and Contra Costa Counties.
Actively participates in clinic team meetings with internal staff and external partners.
Other tasks
Coordinate with the LifeLong Street Medicine teams to support PLWH who are homeless connect with the East Oakland Health Center or other LifeLong clinics, enroll in benefits, and connect to other social services.
Contributes to clinic quality improvement planning and implementation.
Coordinates operation of special projects as assigned by supervisor.
Other duties as assigned by supervisor.
Commitment to the provision of services for the underserved with demonstrated ability and sensitivity in working with a variety of people from low-income populations, with diverse educational, lifestyle, ethnic, and cultural origins.
Excellent interpersonal, verbal, and written communication skills with the ability to handle sensitive issues in a confidential, positive, and professional manner.
Strong organizational, administrative, multi-tasking, prioritization, and problem-solving skills.
Ability to seek direction/approval on essential matters, yet work independently with little onsite supervision, using professional judgment and diplomacy.
Work in a team-oriented environment with a number of professionals with different work styles and support needs.
Conduct oneself in internal and external settings in a way that reflects positively on LifeLong Medical Care as an organization of professional, confident, and sensitive staff.
Ability to see how one’s work intersects with that of other departments of LifeLong Medical Care and that of other partner organizations.
Be creative and mature with a “can do,” proactive attitude and an ability to continuously “scan” the environment, identifying and taking advantage of opportunities for improvement.
Prior experience in counseling patients, either in person or by phone.
Proficient in MS Office/Excel.
Strong customer service approach to problem solving and conflict resolution.
Work/volunteer experience with and a commitment to serve people who are living with HIV/AIDS, people experiencing homelessness, people who are transgender, people of color, women, immigrants regardless of documentation, people who use substances, people with mental health diagnoses, and MSM.
Knowledge of HIV and social services in Alameda County.
ADAP certification. If not certified, completion of successful training and certification is required for continued employment.
Valid CA driver’s license.
