HIV Prevention & Education Coordinator

About the role

As a member of the interdisciplinary care team, this position is responsible for providing administrative and provider support in the delivery of high-quality, patient-centered health care services for individuals living with HIV (referred to as "Special Program" patients). This role focuses on care coordination and administrative support, with special attention to vulnerable populations who may experience barriers to care due to residence, health status, age, personal characteristics, communication challenges, chronic illnesses, comorbidities, substance use disorders, high emergency department utilization, developmental status, or financial circumstances.

Working as part of an interdisciplinary team, the position collaborates closely with pharmacists, LPNs, clinicians, behavioral health providers, and other healthcare professionals to coordinate comprehensive, high-quality, patient-centered care. Travel between health centers is required.

Responsibilities

• Partner with healthcare providers to develop and implement comprehensive care plans that include screening, assessment, referrals, monitoring, and patient advocacy.
• Assist the care team in executing individualized care plans with active patient participation, utilizing networks, referrals, follow-ups, and coordination across medical, social, correctional, and vocational services.
• Facilitate transitions of care, including after hospital discharges and visits to other medical providers, along with social history assessments such as substance use. Obtain necessary medical reports from other providers to ensure smooth transitions.
• Work with patients and their families to set self-management goals and offer coaching on behavioral changes based on practice protocols.
• Refer patients to in-house and external resources like OBGYN, social work, and dental services as per COE guidelines.
• Support patients in connecting them to Medical Case Management services and facilitate Special Program Benefits Program applications for patients in need.
• Educate patients on health topics and arrange specialty visits to improve health outcomes.
• Assist with developing and maintaining systems for care management of patients involved in medication and lab monitoring adherence.
• Complete intake for newly diagnosed or returning-to-care patients and ensure the immediate start of ART (antiretroviral therapy).
• Generate clinical reports using population health management software to identify eligible patients for outreach.
• Track and report individual and aggregate metrics in line with COE guidelines, using DHS-provided Care Management Report tracking sheets, and submit documentation to DHS to demonstrate the achievement of COE goals and benchmarks.
• Organize and participate in community health fair events to attract and enroll community members and raise awareness of HIV, PrEP, post-exposure prophylaxis (PEP), and HIV prevention strategies.
• Complete other duties as requested by the Care Coordination leadership.

Requirements

• A bachelor's degree in sociology, psychology, pre-medical studies, public health, or other related field is preferred but not required.
• Strong interpersonal skills and the ability to present a positive and enthusiastic demeanor while working directly with patients.
• Demonstrated excellent communication, listening, and interpersonal skills. Ability to work effectively with all levels of the care team and other colleagues.
• Demonstrated ability to interpret and apply guidelines and procedures.
• Ability to work with electronic health records (EHR).
• Proficiency in basic computer skills.
• Bilingual skills (English/Spanish) preferred.

Physical Demands

Work is primarily active in nature. Extended periods of time may be spent at a computer terminal.

Work Environment

Work is performed in a busy multi-cultural ambulatory healthcare setting. There is routine exposure to infectious disease, bloodborne pathogens, and other hazards associated with a clinical work environment.

Schedule

Full-time, Monday - Friday.