Position Overview I. SCOPE OF ROLE: Associate's Degree minimum required II. The SRO Intervention Project works with homeless and formerly homeless people with HIV/ AIDSand seeks to connect them to medical services and stabilized housing; The Care CoordinationRedesign Program (CCR) employs a navigation model and a chronic care model to advocate for,communicate with, and identify resources for the client as well as encourage and support clientsto gain and maintain independence in their healthcare to ensure improved client healthoutcomes and improved quality of life. III. ESSENTIAL DUTIES & RESPONSIBILITIES: • Responsible for direct, field-based services to enrolled consumers.• Responsible for supporting the implementation of a comprehensive Service Plan for eachenrolled consumer.• Assist consumers with securing services for housing, medical care, nutrition andtransportation. Assist consumers with relevant applications and other paperwork for benefitsand support services. Conduct regular social services and benefits re-assessments and followups.• Visit enrolled consumers between regular clinic visits to reinforce treatment plans, provideappointment reminders, provide individual health education curriculum, coordinatetransportation and health care needs and other follow up activities as warranted.• Accompany consumers to all primary care, specialty care and other health care appointments.Accompany consumer to other social service appointments as warranted.• Provide field-based Directly Observed Therapy (DOT) Services to consumers assessed torequire this service. DOT includes observing and recording patient medication intake,compliance levels and assessing and reporting any side effects.• Provide critical feedback to the other members of the health care team based on observationsin the field.• Record all service provision for submission on a daily basis.• Facilitate groups for CCR consumers.• Document all services in AWARDS Case Management Software.• Collect and record Primary Care Status Measures data as assigned. • Participate in daily planning meetings with SRO Intervention Project Team. Periodicparticipation in team meetings, case conferences, division meetings and trainings as required• Participate in Services for the Underserved Quality Assurance/ Quality Improvement activities• Reports to the Program Director in the absence of the CCR Supervisor.
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Job Type
Full-time
Career Level
Entry Level
Education Level
Associate degree