JOB SUMMARY
Under the direction of the SSHARC Site Team Leader (STL), The Integrated Care Coordinator (ICC) will work with SSHARC/Cook County HIV Integrated Programs (CCHIP) to assist chronically complex HIV patients to address their specific medical/behavioral needs by managing a comprehensive external referral system. The ICC will provide a range of client-centered, confidential services that link clients with health care, clinical psychosocial, and supportive service for clients living with HIV/AIDS who are identified as having challenges with accessing and maintaining adherence to health care services. The ICC will also provide treatment adherence counseling to ensure readiness for, and adherence to complex HIV/AIDS treatment.
The ICC assists SSHARC/CCHIP multidisciplinary team members who will assist clients in obtaining medical, social, community, legal, financial, and other needed Part A non-medical case management services (NMCM) services. The ICC will assure that client is connecting to other core services: Dental, Mental Health and Substance Abuse treatment. The ICC will work alongside the SSHARC multidisciplinary team and the SSHARC Medical Case Manager to assist with completing annual and six-month recertification for Ryan White HIV/AIDS Program Eligibility (RWHAP). The ICC will also provide benefits counseling to clients and assist in enrollment, verification, and utilization of those benefits. The ICC will collaborate with the CCHIP Specialty Care Coordinator to manage Population Centered Health Home (PCHH) Domain 4: Referral Services and linkage agreements. The ICC directly supervises the SSHARC IDPH RIG 8 Prevention contractors and oversees the RIG 8 program activities. The ICC works alongside the SSHARC Site Team Leader and EIS/Outreach team to plan and assist with community HIV testing coordination, HIV linkage and re-engagement to HIV primary care as needed.
SPECIFIC RESPONSIBILITIES
- Alongside the SSHARC MCM, complete initial RWHAP Eligibility Intake and re-assessment of needs on all new clients.
- Develop a short-term, individualized service plan and assist with the completion, collection and documentation of ADAP for closed MCM clients.
- Maintain contact with client to assure Medical, Supportive Services and Medication
- Make appropriate and timely referral to internal and external providers coordinate services identified on service plan.
- The ICC will meet with Medical Providers every six month to collaborate and evaluate client’s compliance to medical appointments and maintain viral suppression.
- Properly transition clients out of Non-Medical Case Management/Engagement Service into other appropriate programs.
- Adhere to Social Services Documentation Policy of all Patient Encounters and Forms in the appropriate systems.
- Work alongside the SSHARC Behavioral Health Provider to coordinate the activities of the Consumer Advisory Board (CAB). Works alongside the CCHIP Consumer Development & Advocacy Coordinator to ensure SSHARC patients participate in CCHIP Joint CAB
- Co-Lead the SSHARC Quality Improvement Committee alongside the SSHARC STL. Attend monthly CCHIP CQI meetings at the RMR CORE Work collaboratively with the SSHARC
STL Manager and CCHIP Regional Director of Quality Improvement & Evaluation on CQI projects and activities.
- Work alongside the CCHIP Program Director to ensure client eligibility for CCHIP NMCM Communicate with CCHIP Data Team to review documentation of non-medical case management services in CAREWARE and the CCH electronic medical record (EMR).
- Attend SSHARC case conferences, CCHIP mandatory meetings and staff
- Monitor SSHARC provider schedules and assist with multidisciplinary case conferences as
- Work Alongside SSHARC STL to ensure all prevention staff receive training on PrEP, EIS activities, including but not limited to HIV Testing, Health Education & Literacy Training, Referrals and Community Outreach/Events.
- Promote SSHARC HIV program services and collaborate with community partners, identify new locations for sexual health service delivery (inclusive of HIV Testing, PrEP, Condom Distribution). Work alongside the CCHIP Specialty Care Coordinator to assist with new & expired linkage
- Participate in all Mandatory Trainings
- Other Duties as assigned
QUALIFICATIONS – Knowledge/Skills/Experience
Formal Education Required: Bachelor’s Degree in Public Health, Public Administration, Community Health, Human Services, Social Work or other health related field or a minimum of two years providing direct HIV prevention/social services experience required. Required Supervisory or Management Experience: 1 year Experience working in a hospital, social service or outpatient setting preferred.
Knowledge and experience working with diverse and complex clients preferred. Microsoft Office Programs and Intermediate Computer experience required. Experience working with clients with multiple needs.
Comfortable working with diverse clients and traveling to different sites for work.
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