Case Manager - HIV

Job Duties

• Care coordination
• Primary Care coordination
• Help retain PLWH in care at the East Oakland Health Center
• Reengage patients who have had a lapse in medical care
• Coordinate health care for individuals in need of assistance with adherence to medication
• Help PLWH maintain an undetectable viral load
• Assist with medication reconciliation
• Link newly identified PLWH to available social services
• Engage marginally housed adults in primary care services
• Provide clinically and culturally sensitive outreach services
• Intervene in crisis situations, provide brief behavioral interventions, and conduct psychosocial assessments
• Collaborate with outside service providers and make appropriate internal/external referrals
• Assist patients in navigating the requirements of medical insurance
• Enroll patients in AIDS Drug Assistance Program
• Ensure access to community services
• Track, manage, and facilitate specialty referrals
• Make appointments and complete reminder calls for primary care provider panel
• Document client progress, referrals, encounters, services, and treatment progress
• Support patients in navigating barriers to care, treatment, and social support
• Assist patients in enrolling in benefits and connecting to other social services
• Contribute to clinic quality improvement planning and implementation
• Coordinate operation of special projects as assigned by supervisor

Documentation

• Enter all encounters and units of service into the electronic medical record Epic, ARIES, and other data management systems as required
• Maintain documentation of services to allow compliance with required reporting
• Maintain 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)

• Coach PLWH in self-management (e.g., medication adherence, lifestyle)
• Absorb patients in developing and executing health-related action plans or behavior changes based on client goals
• Navigate problem-solving with patients as they encounter obstacles to achieving health-related goals
• Conduct brief interventions with patients regarding alcohol and tobacco use and other behavioral health issues as appropriate

Agency and Clinic Meetings

• Participate in weekly case conferences with the HIV-Access team and monthly HIV Care and Prevention team meetings
• Represent 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
• Coordinate with other clinics within Lifelong Medical Care and across Alameda and Contra Costa Counties
• Actively participate 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