Linkage to Care Coordinator

Vivent Health-posted 2 months ago
Milwaukee, WI
251-500 employees
Religious, Grantmaking, Civic, Professional, and Similar Organizations
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The Linkage to Care Coordinator provides intensive care coordination, support and services to HIV-positive individuals who require rigorous assistance to improve their ability to access and remain in care. This individual will coordinate with HIV testing sites as needed to initiate access to care; work with clinical staff to promote adherence to medical, behavioral, oral health and pharmaceutical care; provide treatment education; collaborate with other programs within Vivent Health and with local providers; and offer direct interventions to reduce barriers to care for the benefit of patients. The Linkage to Care Coordinator will also educate HIV positive individuals on the importance of HIV medical care and empower them to navigate medical and social systems on their own.

  • Provide highly focused, intensive, time-limited support to persons newly diagnosed with HIV disease, persons from corrections facilities who are returning to the community, persons at high risk for falling out of care, or who have lapsed from care.
  • Conduct immediate response for newly diagnosed clients in clinic or outside testing partner agencies as assigned.
  • Complete intake and other screenings to identify barriers to care and, with the patient, devise possible solutions that are effective and sustainable.
  • Provide case management services, according to the state HIV Medical Case Management Standards, to persons with HIV infection through assessments, service planning, coordination of services and/or service plan monitoring.
  • Work with appropriate community physicians, nurse practitioners, therapists, dentists, pharmacists, and case managers to identify patient health needs and to ensure accessible, confidential, and high-quality services to patients.
  • Work with patient and providers to develop and implement a health care plan to meet patient needs and retain patient in care.
  • Assess benefits and insurance, and if needed, provide assistance to access payor programs.
  • Facilitate communication among the care team.
  • Provide HIV disease prevention and treatment adherence education.
  • Assist with making appropriate referrals for services needed to stabilize patient in care and follow-up to ensure service delivery.
  • Accompany patients to health appointments; in consultation with the supervisor, this may include transportation to and from and attendance at the appointment.
  • Provide a level of service that is highly intensive, involving large amounts of time in the community, at patient homes and in other locations that meet the patient's needs best.
  • Contribute as an active member of the Social Services Department by participating in staff meetings, in-service trainings and workshops, department or agency planning activities, assisting with special projects, and providing support, peer mentoring and training to co-workers as needed.
  • Collaborate extensively with Vivent Health's Medical, Dental, Pharmacy, and Behavioral Health Clinics personnel to ensure that clients obtain appropriate and timely access to all needed care.
  • Establish a working relationship with appropriate community resources in the area, including those providing HIV testing and/or health, mental health and social services to underserved and target populations.
  • Maintain appropriate patient files and timely documentation of services utilizing electronic case management and/or medical software.
  • Update and maintain a strong working knowledge of HIV/AIDS, treatment options, risk reduction techniques, chronic diseases, mental health issues, case management, and other related issues through self-study and participation in trainings.
  • Collaborate as team member to achieve organizational and department goals including participation in rotating on call coverage.
  • Bachelor's degree in social work, health care, or a human service discipline from an accredited college or university is required.
  • 2+ years' experience in outreach-type activities, conducting screening, providing education and/or direct services in a community-based health clinic or social service environment.
  • Must have a valid driver's license.
  • Local Travel for Home/Community Visits, Med Appts, etc.
  • Knowledge of and sensitivity to the HIV/AIDS patient population, and/or an eagerness to learn about this community.
  • Extensive knowledge of medical, social and mental health delivery systems.
  • Extensive knowledge of HIV disease and related issues, disease progression, and treatment options.
  • Demonstrated effective written and verbal communication skills, including client-centered communication and assessment skills.
  • Ability to establish and maintain effective public and working relationships with culturally diverse populations from a wide range of life circumstances and backgrounds.
  • Ability to effectively organize work products and files, keep clear records, and manage time well.
  • Working knowledge of Spanish language (bilingual) is a plus.
  • 6 weeks of paid time off in the first year (divided into different categories)
  • 12 days of paid holidays
  • 401k with 100% employer match up to 5%
  • 12 weeks of fully paid parental leave
  • Employer subsidized medical, dental, vision benefits
  • Gender-affirming care benefits
  • Employer paid short and long-term disability
  • Tuition reimbursement
  • Certification and licensure assistance
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