Function:

Under the general supervision of the Care Coordination Nurse Manager and Administrative Manager, High Acuity Community Health Worker Program, provides case management, health navigation services, and coordinates referrals to community resources to people living with HIV/AIDS (PLWHA) who require enhanced care to maintain viral suppression, engagement in care and successfully manage social determinants of health.

Representative Duties:

Provides case management services to PLWHA patients with high level of need and poor medical compliance:

• Provides services to patients who have poor medical compliance, uncontrolled HIV viral load, or who otherwise are identified as high risk.
• Forms productive, empathic working relationships with assigned patients on their caseload
• Screens eligibility and reviews medical, mental health and social history of patients in need of intensive case management services, identifies needs, and refers patients as appropriate in a timely, courteous manner. Referrals may include need for further assessment/evaluation by licensed clinicians or review by a supervisor.
• Provides high level of support to ensure barriers to poor medical and medication compliance are mitigated
• Provides information to patients about available community resources and assists patients to determine eligibility and obtain services
• Provides on-going support to patients as appropriate and conducts outreach to help retain patients in care or to encourage patients to utilize additional necessary services
• Links medical patients when appropriate to mental health and substance abuse services
• Interacts with patients in community settings (home visits, community locations, hospitals, other program sites)
• Meets established service delivery targets
• Adheres to NASW Code of Ethics

Collaborates with other agencies:

• Develops and maintains resource listings appropriate for Fenway Health patients
• Participates in community councils, boards and groups as appropriate to further departmental objectives
• Works with Medicaid, Medicare, Welfare, Social Security, housing, educational, day care and other institutions to assist clients
• Consults with a variety of health center and community staff (Nutritionists, Home Health Aides, Nurses, Behavioral Health staff and Medical staff) about specific clients and general approaches to patient treatment

Performs and completes administrative tasks in a timely and efficient manner:

• Completes psychosocial assessments and care plans for newly enrolled patients
• Writes case notes for each patient interaction
• Collects necessary programmatic documentation and maintain up-to-date patient files and charts
• Assists patients with applications for enrollment in entitlement programs
• Assists medical teams with case management administrative tasks
• Participates in staff and team meetings and conferences
• Participates in professional activities to maintain professional standing
• Participates in program reporting and accountability as required by funding agencies

Meets agency participatory expectations:

• Suggests and participates in continuing quality improvement efforts
• Adheres to all agency and departmental policies and procedures
• Participates in quality assessment and improvement activities as requested
• Adheres to the highest principles of patient and client confidentiality
• Adheres to established safety policies, procedures and precautions; identifies potential or actual unsafe situations in the environment and takes measures to rectify the situation
• Attends all required meetings, in-services and professional trainings
• Attends all regularly scheduled research meetings, trainings, forums and pertinent FCH staff meetings
• Maintains professional competence necessary to perform job responsibilities; maintains and provides agency with records of continuing education activities
• Serves on agency committees and in professional organizations when requested

Performs related duties as required

• Requires a Bachelor's Degree
• Relevant experience may be substituted for educational requirement
• Ability to work harmoniously and effectively with colleagues, patients, clients and vendors across the spectrum of diversity, including but not limited to race, ethnicity, color, gender identity, sexual orientation, age, socio-economic status, national origin and immigrant status, religious or spiritual identity, disability (physical, mental, emotional and developmental), veteran status, and/or limited English proficiency.
• Willingness to contribute towards Fenway's efforts in becoming an anti-racist organization and promoting a culture dedicated to ongoing development in service of humility, equity, diversity, inclusion, and belonging, where differences are acknowledged and valued.

Preferred Qualifications:

• Preferred Qualifications
• Spanish speaking strongly preferred
• Experience with LGBTQIA population preferred
• Prior case management experience in a medical or community setting and experience working with people who have HIV preferred
• Excellent interpersonal skills and ability to be an effective team member, while working frequently off-site
• Flexibility, adaptability, independence, and ability to multitask required
• Experience working with an ethnically, culturally and racially diverse work staff preferred

Physical Requirements:

• Ability to meet the following physical requirements with or without reasonable accommodations:
• Sit at a computer station for extended periods of time
• Ability to keyboard for extended periods of time
• Ability to make community visits, travel regularly, and work in non-office settings