Provides Intake, Assessment, Individual Service plans and ongoing case management for patients living with HIV/AIDS.
Practices under DPH, HRSA HAB, and BPHC case management standards of care and periodically evaluates and ensures that standards are met.
Regularly assesses case management services and identifies areas of growth and improvement.
Coordinates health and social services for clients.
Evaluates progress toward service plan goals & objectives and ensures eligibility requirements are met and documented.
Assures that clients are connected to needed community services as well as financial benefits/entitlements.
Empowers clients for self-advocacy as appropriate.
Assists in operation of weekly Tuesday food pantry at Daniel Driscoll Neponset Health Center between 7:30 AM and 3:00 PM a minimum of once per month.
Additional assistance required as needed with priority availability between the hours of 7:30 AM and 9:30 AM.
Supports food access programs including coordinating meal delivery and tracking food access support services such as grocery store gift cards.
Actively participates in assigned continuous quality improvement activities for case management program.
Conducts off-site client social services and health visits when appropriate.
Establishes & maintains relationships with outside community agencies providing useful services for clients.
Contributes to the collection and maintenance of demographic and service utilization data for grant and contract requirements as appropriate including monthly reporting.
Collaborates with medical and other staff to develop and implement patient care plans via multidisciplinary case conferences and individual provider meetings.
Timely and accurately records necessary and pertinent data in client’s medical record following HHSI policies and procedures.
Engages patient to help manage appointments and referrals and maintains monthly outreach to patients for engagement.
Attends monthly department meetings, mandatory and non-mandatory trainings, and conferences.
Assists clients in accessing core and supportive services of medical transportation, mental health referrals, oral health care and nutrition.
Participates in annual Part A BPHC Site Visits, and HRSA Site visits and contributes to preparations of audit.
Requirements
Bachelor’s degree in Social Work, Human Services or related field required
BLS (Basic Life Support for Healthcare Providers) Certification required
License in Social Work (LSW) or LADC (License in Alcohol and Drug Counseling) or five years of experience in Case Management may be substituted for the BA/BS degree
Master’s Degree in Psychology, Human Services, Social Work, Education or closely related field may be substituted for professional experience
One year of Case Management experience
Ability to work independently and cooperatively as part of a multidisciplinary team
Ability to prioritize, organize and schedule busy workdays
Basic business writing skills
Basic skills in effectively using Office 365 applications including Word, Excel and Outlook and Teams
Required to travel to, and provide services in, client's residence as necessary; must be able to travel between Harbor and outside sites in a timely manner