Case Coordinator - Pathways Center

Case Coordinator

Under the supervision of the Director of DAC Services and Programs, the Case Coordinator performs a variety of coordination services to all patients engaged in any clinical discipline within the Pathways Center. The Case Coordinator complies with the standards of care management for HIV+ primary care patients and assists other patients based on patient-centered identified needs.

1. Perform an initial assessment and annual re-assessment for each client enrolling in the HIV primary care program.

2. Develop a service plan to address needs identified in the assessments.

3. Coordinate services to complete the items in the service plan.

4. Coordinate and sustain connection of patients with appropriate SBH resources including Health & Wellness, Population Health, Health Home, care management, other special programs, and community resources.

5. Provide supportive services, such as medication adherence and HIV prevention education, to patients enrolled in HIV primary care and HIV prevention programs.

6. Assist patients engaged in the Infectious Disease practice as requested by the Infectious Disease Specialist.

7. Coordinate outreach to encourage patient engagement in care and to help close relevant care gaps in a timely manner in the HIV primary care, HIV prevention, and Infectious Disease programs.

8. Collaborate with providers, case managers, social workers and others to ensure timely patient access to all required services or programs to address patient needs.

9. Facilitate intake for newly diagnosed HIV positive individuals in HIV primary care, whether through referral, escort to the program, or walk-in.

10. Accurately document all service related activities in the Center's electronic health record.

11. Participate in program and/or departmental quality assurance activities as requested.

12. Perform any tasks assigned by the Program Director related to departmental activities as requested.

13. Attend scheduled department and division meetings and participate as appropriate.

Bachelor's degree required.

Experience required in HIV case management, treatment adherence, or care coordination, preferably in a supervisory, team leader, or task assignment/follow-up capacity.

Extensive knowledge of HIV transmission, prevention, adherence, and viral suppression.

Ability to work independently and effectively meet deadlines.

Good organizational, writing, verbal, and interpersonal skills.

Basic computer skills, including Microsoft Excel and Word.

Bi-lingual, Spanish/English preferred.