CCHIP - CASE MANAGER, BILINGUAL - CORE CENTER

Cook County•Chicago, IL

9d•Onsite

About The Position

The CCHIP Case Management (CM), Bilingual will provide a range of client-centered, confidential services that link clients with health care, clinical psychosocial, and supportive service for clients living with HIV/AIDS who are identified as having challenges with accessing and maintaining adherence to health care services. Works closely with the CORE Center medical team to stabilize clients’ medically. Facilitates linkage to and maintenance of clients to their primary medical services. The CM will also provide treatment adherence counseling to ensure readiness for, and adherence to complex HIV/AIDS treatments. The CM will assure that client is connecting to other core services; dental, Mental Health and Substance Abuse treatment. This case manager will also provide benefits counseling to clients and assist in enrollment, verification, and utilization of those benefits. The CM will provide case management to special populations. This is a grant-funded position. Grant -CCH Ryan White pt B Reentry Region 8 will expire on June 30th, 2026, with the potential to be renewed.

Requirements

Associate’s degree in related human service, social science, or health education field from an accredited college or university with two (2) years of experience working LGBTQIA and/or HIV/AIDS clients with multiple needs OR Bachelor’s degree in related human service, social science, or health education field from an accredited college or university with prior experience working with LGBTQIA and/or HIV/AIDS clients with multiple needs
Proficiency using Microsoft Office including Access and similar database programs
Must obtain and maintain an Aids Foundation of Chicago (AFC) Medical Case Management Certification within first 6 months of employment
Bilingual in Spanish is required (Bilingual testing for Spanish will be administered, 80%25 minimum score is required)
Knowledge of HIV/AIDS and family issues, commitment to confidentiality, ethics, and a culturally sensitive approach to counseling
Excellent verbal, written communication, and interpersonal skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age groups
Strong customer service and empathy skills
Ability to function autonomously and as a team member
Ability to adhere to department policies and standards, utilizing best practices
Ability to maintain a professional demeanor and composure when challenged
Ability to handle confidential information

Nice To Haves

Three (3) years of experience working with HIV/AIDS clients with multiple needs
Licensed LSW or LCSW
Experience working in a primary care medical setting, hospital, or outpatient setting, and/or with clients with multiple needs

Responsibilities

Completes initial intake and assessment of needs on new clients and clients returning to care.
If opened for CM services, complete Aids Foundation of Chicago (AFC) intake documentation
Make all initial referrals to Behavioral Health, Health education, dental, and benefits.
Assess benefits and complete necessary applications and referrals
Maintain a caseload based on funder’s requirements
Develops a comprehensive, individualized service plan
Reviews with client, client will agree to the goals and objectives for the services plan that will include specific outcomes with expected completion dates and timelines
Conducts periodic re-evaluations at least once every 6 months review whether the goals were met and should continue or discontinue and/or make new goals, if needed
Collaborates with medical provider and other clinic staff to assure compliance with the service plan
Maintains contact with client to assure medical and medication compliance
Contacts client prior to scheduled medical appointments to remind them of their appointment
Performs face-to-face contact with client at least once every three months and have phone contact with client monthly in between those face-to-face contacts
Conducts outreach if client becomes non-compliant by doing phone outreach, sending a letter to last known address, and complete home visit to encourage compliance with medical and medication
Advocates and reinforces education to client of the expectations of client around clinic appointments (ensuring client meets with CM at appointment), medication adherence and compliance to all referral to Substance Abuse and Mental Health Services
Identifies barriers to appointments and provide support to encourage adherence. For example, the CM will access for transportation needs and provide transportation, if needed
Makes appropriate and timely referral to internal and external providers and coordinate services identified on service plan
Makes referrals and documents in electronic databases
Follow-up on referrals will be made to provide necessary information and support to facilitate the referral
Meets with medical provider on a regular basis to mutually support client’s compliance with appointments
Presents during clients' scheduled medical appointments to advocate on client's behalf for any identified or assessed services
Attends all pre-clinics to give updates on client's social service needs and collaborate with other providers
Completes a CM care conference with a licensed provider on all active clients at least once every 6 months
Transitions clients out of medical case management into other appropriate programs
Completes change of status after meeting all goals of the service plan and client deemed stable, transfers case into supportive case management or close
If medically indicated, the client should refer to DRS services
Maintains the client on their caseload until the client is deemed stable
Refers client to educational support groups if appropriate
If client would like to transfer to another agency within the Case Management Cooperative, the appropriate transfer steps should be taken per AFC Standards of Procedure
Adheres to Social Services Documentation Policy of all patient encounters and forms
Documents face to face conversations, phone calls, and collateral contacts must be in the electronic medical record, and all other databases
All client-related activities, referrals including approvals and denials should be in patient record and database
Enters data and paperwork will be submitted in compliance with the policies
All transportation, food vouchers, cabs, Uber rides must be properly documented, including client’s signature of receipt
Tracks any client or service trends and report in monthly supervision
Maintains a working knowledge of community and internal program that would enhance the client’s ability to be maintained in care
Attends any workshop that would familiarize case manager with community programs
Keeps a resource file of HIV/AIDS programs with contact information
Remains current with AIDS Drug Assistance Programs (ADAP), CareLink, CountyCare, Medicare D programs and benefits programs that would benefit the clients
Enhances professional development and maintain an area of specialization
Discusses areas of specialization and interest with supervisor, seek and receive ongoing training in specialty area (ob/gyn, community outreach, women specific issues), periodically present cases or topics related to specialty area to case management department and/or social service staff
Maintains professional competencies and complete at least 12 trainings per year
Participates in all CORE Center and AFC mandatory training and meeting
Completes and pass AFC Medical Case Management Certification within first 6 months of employment, maintains certification
Attends and certificate of completion for all trainings will go in employee’s record of all mandatory training. Any training that is missed should have supervisor’s approval
Participates in social services continuous quality improvement efforts
Meets documentation requirements as outlined within the Social Services Department and throughout the CORE Center
Develops quality improvement processes as assigned
Adheres to CORE Center and social services specific policies and procedures
Provides excellent customer service and professionals when interacting with clients and internal and external customers
Responds to phone calls, emails, faxes and pages in according to the CORE policies
Maintains open communication with supervisors and communicate concerns through the appropriate means
Provides clinic coverage/general coverage when a shortage arises
Facilitates groups upon request
Performs other duties as assigned