Salary: $21.00 – $22.00 Hourly

Classification: Full-time, Non-Exempt. Thirty-five-hour (35.00) week; evenings and weekends expected for meetings, workshops, and seminars. Apply:

Minimum Qualifications:

1. BA or BS and a minimum of two (2) years’ experience in health and human services, or a related field working in the field of HIV/AIDS, behavioral health, substance abuse or other chronic illnesses.

2. Familiarity with and experience in housing and working with at risk homelessness preferred.

3. Sensitivity to HIV/AIDS, chronic illness, LGBTQ issues and a strong commitment to the mission, vision, and values of ACR health are essential

4. Ability to work with diverse populations

5. Possess a clear understanding of community level work and the importance of collaborating and coordinating with other organizations.

6. Effective communication and documentation skills, as well as cultural and linguistic competence.

7. Access to a reliable and insured vehicle is required for necessary travel throughout a multi-county region.

Primary Responsibilities:

1. Incorporate best practices regarding confidentiality into all job duties and communications in accordance with Article 27-F and HIPAA, ACR Health policies and procedures and other applicable regulations. Protect agency data in accordance with confidentiality procedures and protocols. Observe and abide by the HIV Confidentiality Law and HIPAA.

2. Engage the client that is not in care or sporadically in care. Employ techniques to actively support the client in activities that improve their health outcomes resulting in sustained viral load suppression.

3. Develop individual care plans in conjunction with the client, Health Educator, and related service providers.

4. Provide direct access to services through immediate and timely response to client needs and involved service providers.

5. Incorporates a solution focused case management model with frequent client and provider contracts, regular monitoring and medical updates, quarterly reassessments, and case conferences.

6. Conduct multidisciplinary case conferences and coordinate services and referrals with services and clinical providers that facilitate a client’s engagement and retention in care.

7. Address and remove barriers t enable client access to all necessary components of health care, including mental health and substance abuse services.

8. Negotiate and advocate on behalf of clients for services that support self-sufficiency and self-management including for medical, legal, social, financial, housing and other services as appropriate.

9. Collaborate with the Health Educator to identify needed and appropriate health education services for clients.

10. Work with Peer Navigators to engage clients into care and treatment and support services.

11. Maintain complete and accurate statistical information; prepare all required monthly and program reports as assigned; ensure thorough, up to date and complete client records.

12. Complete/submit all required documentation within designated time frames.

13. Ensure proactive and productive linkages with area social services providers.

14. Authorize and arrange for necessary support, medical and stabilizing services for the client to develop and maintain effective health care.

15. Develop and maintain working knowledge of all area service providers and client resources; keep abreast of developments in the medical, behavioral, social service, legal and other areas related to client services provision.

16. Maintain weekly contact with Clients. Conduct home visits on a regular basis. Meet with the client’s support network when appropriate to assess responsiveness of the care plan.

17. Coordinate services with local providers agencies to ensure comprehensive approach, to include ongoing communication with Hospital Care Workers and Discharge Planners.

18. Re-evaluate care plan, conduct case conferences on a regular basis to ensure continuity of services.

19. Ensure interventions are consistent with identified long/short term goals, care plans and needs assessment. Complete reassessments and modify are plan/goals as appropriate.

20. Maintain working knowledge of care management program regulations, policies, and procedures.

21. Attend and log all required and recommended staff trainings and in-services.

22. Perform other duties as assigned by program Supervisor, Manager, Director, Chief Program Officer and/or Chief Executive Officer.