The RN Care Manager – HIV care and prevention provides intensive, relationship-based care coordination, patient navigation, and population health management services for individuals living with HIV and individuals at increased risk for HIV acquisition. This role serves diverse populations, including individuals experiencing social complexity, housing instability, substance use disorders, behavioral health concerns, and members of LGBTQ+ communities.
The RN Care manager functions as a central point of coordination for patients receiving HIV treatment, prevention, and support services. Responsibilities include promoting engagement in care, treatment adherence, viral suppression, HIV prevention strategies, care coordination across healthcare and community settings, quality improvement activities, and reducing barriers that impact health outcomes.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Patient Identification and Enrollment
- Identify and engage patients who may benefit from HIV treatment and prevention case management services using established clinical, behavioral, social, and population health criteria.
- Utilize population health tools, registries, screening results, laboratory data, and risk stratification reports to identify patients requiring HIV-related care coordination, prevention services, or engagement support.
- Participate in interdisciplinary case review and patient prioritization, incorporating both data-driven identification and provider/team referral.
- Maintain active case management oversight of patients receiving HIV treatment services and manage an assigned panel of HIV prevention patients based on program capacity and patient need.
- Reassess patient enrollment status and level of intervention at regular intervals using established program criteria.
Care Coordination
- Develop individualized, patient-centered care plans in collaboration with patients and care teams, incorporating patient-defined goals and preferences.
- Coordinate care across primary care, behavioral health, infectious disease specialists, pharmacies, hospitals, community organizations, and public health partners.
- Support timely linkage to HIV medical care, prevention services, laboratory monitoring, treatment initiation, and ongoing follow-up.
- Assist patients in overcoming barriers related to transportation, housing instability, medication access, insurance issues, stigma, food insecurity, and healthcare system navigation.
- Facilitate warm handoffs between team members and services.
- Coordinate with community providers to extend outreach, social support, coaching, advocacy, and navigation services.
Patient Engagement
Build therapeutic, trauma-informed relationships with individuals impacted by HIV and those at increased risk of HIV acquisition.
- Conduct outreach via phone, text, telehealth, and in-person encounters.
- Provide education regarding HIV prevention, treatment, medication adherence, viral suppression, risk reduction, and available support services.
- Facilitate or co-facilitate individual and group education sessions focused on HIV care and prevention, including treatment adherence, viral suppression, and strategies to reduce risk of HIV acquisition and transmission.
- Utilize motivational interviewing techniques to promote engagement in care, treatment adherence, prevention services, and self-management.
- Support patients in maintaining long-term engagement in HIV care and prevention services.
Clinical Support
- Monitor and support adherence to HIV treatment and prevention plans, escalating concerns and care gaps to the appropriate clinical team members.
- Track laboratory monitoring, preventive screenings, and follow-up care consistent with HIV treatment and prevention guidelines.
- Administer and track standardized screening tools.
- Assist with coordination of preventive care, specialty referrals, and follow-up appointments.
Quality Improvement and Population Health
- Utilize registries, reports, laboratory data, and population health tools to monitor program outcomes and identify opportunities for improvement.
- Monitor HIV-related quality indicators, including linkage to care, retention in care, viral suppression, prevention engagement, and other grant and program performance measures.
- Identify trends, barriers, and workflow challenges impacting patient outcomes and proactively recommend solutions.
- Collaborate with leadership and interdisciplinary teams to develop, implement, and evaluate quality improvement initiatives.
- Participate in program evaluation and performance reporting activities.
Collaboration and Documentation
- Participate in interdisciplinary team meetings and case conferences.
- Document patient interactions, care plans, screening results, interventions, and outcome measures accurately within the electronic health record.
- Participate in community and state-level partnerships, including advisory groups, to support planning, coordination, and improvement of HIV care and prevention services.
- Support training of clinic staff on risk identification, patient engagement, and evidence-based care management approaches for people at increased risk of HIV.
- Assist with facilitation, coordination, or support of educational activities and external training opportunities.
- Attend monthly clinic meetings, Nursing Department meetings, and daily POD huddles.
- Assist with onboarding and training of clinical staff as indicated.
KNOWLEDGE, SKILLS AND ABILITIES:
ANHC’s Mission, Vision and Values: Actively supports ANHC’s mission, vision and values. Includes using individual skills to add value to the mission: To be a trusted partner in every person’s wellness by providing integrated, compassionate, and high-quality health care, regardless of ability to pay; and vision: Accessible care for a healthy Anchorage. Aligns actions around organizational values of RESPECT, COMPASSION, PERSONAL INTEGRITY, EXCELLENCE and COLLABORATIVE SPIRIT and gives priority to organizational mission, vision and values when making decisions.
Accountability: Takes ownership for delivering on commitments; owns mistakes and uses them as opportunities for learning and development; openly discusses his/her actions and their consequences both good and bad; has an ability to identify strengths and developmental opportunities and leverages insight to make adjustments to improve their effectiveness; courage to have difficult conversations.
Adapting to Change: Accepts and adapts to change in a professionally appropriate and thoughtful manner. Is willing to offer a different perspective or approach and yet knows when and how to stand down graciously and accept a well-thought-out decision. Embraces change.
Confidentiality: Maintains the highest level of confidentiality regarding ANHC records and information relating to ANHC, its customers and employees. Appropriately uses internal confidential information for business purposes only. Responsible for knowledge and compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Communicating Effectively: Shares information. Listens and involves others. Clearly conveys ideas in a manner that engages others and helps them understand and retain the message.
Decision Making/Judgment: Approaches problems and decisions methodically and objectively; involves others as needed; uses sound judgment in making decisions and understanding the impact to themselves, customers, their team, and the organization; conducts the appropriate analysis to identify the symptoms and root cause of issues; makes timely decisions.
Delivering High Quality Work: Makes sure responsibilities central to the role meet all requirements and expectations. Finishes tasks promptly and critically reviews work to ensure quality and accuracy. Considers impact of work to others and takes steps to mitigate. Seeks additional work after finishing tasks.
Demonstrating Initiative: Takes action on his/her own without being prompted; handles problems independently; able to resolve issues without relying on extensive help from others; does more than is expected or asked.
Results Orientation: Is focused on outcomes and accomplishments; follows through on commitments; can be counted upon to successfully execute on goals; motivated by achievement and a need for closure; has an attention to detail and is both efficient and effective in achieving a high level of measurable outcomes; persists in achieving goals despite obstacles.
Service Excellence: Has a desire to consistently provide a genuinely exceptional experience to every person, every time. Provides timely and professional service to both internal and external customers; is responsive to customer needs and requests; is always courteous to the customer and considers the needs of the customer when making decisions.
Teamwork: Meets all team deadlines and responsibilities, listens to others and values opinions, helps team and leader to meet goals, welcomes newcomers and promotes a team atmosphere.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.
Work Experience: Four years of progressively responsible nursing experience in primary care, ambulatory care, community health, or population health setting. Experience working within a Patient-Centered Medical Home (PCMH) model preferred.
Education, Certification and Licensure: Active license as a Registered Nurse in the State of Alaska. Must have and maintain current BLS certification.
Additional Skills & Knowledge: Bilingual skills preferred. Participate in ongoing professional development activities to support excellence in HIV care and prevention services. Maintain current knowledge of evidence-based HIV treatment, prevention strategies, emerging best practices, Ryan White program requirements, and relevant state and federal guidelines.
PHYSICAL, SENSORY, ENVIRONMENTAL QUALIFICATIONS:
The work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
While performing the duties of this job, the employee is frequently required to sit and occasionally required to walk and stand. The employee may occasionally be required to lift and/or move up to 20 pounds.
Work is performed in a healthcare clinic and office setting. ANHC is a tobacco-free campus.
EQUAL EMPLOYMENT OPPORTUNITY STATEMENT:
Anchorage Neighborhood Health Center provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, marital status, amnesty, or status as a covered veteran in accordance with applicable federal, state and local laws. Anchorage Neighborhood Health Center complies with applicable state and local laws governing non-discrimination in employment in every location in which the organization has facilities. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training. Persons alleging unequal treatment should contact the Chief Human Resources Officer.
The undersigned have read this job description and agree that it defines the position as it currently exists. The undersigned also understands that the above is intended to describe the general content of and requirements for this job. It is not to be considered as an exhaustive statement of duties, responsibilities, or requirements and does not limit the assignment of additional duties at the discretion of the supervisor.
