Case Coordinator – Pathways Center

Job description

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...