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Position Summary:

Under the direct supervision of the Coordinated Services Supervisor, the Case Manager is responsible for assisting people with HIV/AIDS access the continuum of HIV care services. The Case Manager will be responsible for providing direct services, and coordinating services for clients who are HIV+ and conducting a comprehensive uniform assessment in the following areas: health status, medical care and provider, activities of daily living and mental health status. The Case manager will be responsible for maintaining comprehensive files for each client and developing a care plan based on client needs. Will represent Our Place in the community, interacting and networking with community service agencies that provide services to HIV positive individuals and their families. Cultivates and maintains communication and networking with multi-ethnic organizations in the HIV/AIDS community. Serves as a role model for cultural and linguistic competency. Maintain client confidentiality at all levels.

This is a full-time, temporary assignment through December 2026. Extension or conversion based on business needs.

Essential Functions of the Job:

• Develop excellence in case management services which will enrich and enhance the quality of life, dignity and respect of people living with HIV, to a caseload of 30-50 clients (caseload may be adjusted based on acuity level of caseload)
• Conduct an initial comprehensive acuity assessment to determine the medical, psychosocial, and social service needs of clients living with HIV and refer accordingly to the appropriate level of care. Assessment is completed at intake and a reassessment every 120 days at minimum. Face to face contact at a minimum of every 90 days and phone contact with clients to review created care plan is completed at minimum of once every 30 days
• Ensure clients are enrolled in medical care, have appropriate coverage (ADAP and Ryan White), and provide coordination and follow-up of medical treatment. Identify barriers to care and barriers to retention in care. Support the successful completion of appropriate referrals to resources and services including: (but are not limited to): transportation, medication assistance, housing, mental health counseling, substance use counseling, legal services, food assistance, financial assistance, etc. and advocate for the procurement of benefits and services
• Timely professional maintenance of records and documentation, including progress notes, treatment plans and ongoing evaluation of client progress, consistent with scope of work, agency expectations and ethical standards. Responsible for entering all required client related data into ARIES within 2 business days of completing the service
• Implement Evidence Based Practices (EBP) such as: Motivational Interviewing, Trauma-Informed Care, Harm Reduction and Person-Centered Care approach. Actively partner, utilizing EBP’s, with clients to identify their priorities to develop the care plan to clearly define areas for needed services
• Assists the Coordinated Services Supervisor in monitoring the quality assurance and evaluation process ensuring contract compliance and outcome and process objectives for clients and their families are met. Assists in the preparation of monthly narrative and statistical reports covering progress toward meeting outcome and process objectives established in the case management contract
• Increase relationships and communication with other San Ysidro Health programs and locations. Represent San Ysidro Health and the HIV department to other programs, organizations and community groups.  Network with other HIV and social support service providers. Participate in all multi-disciplinary team meetings, staff meetings, and selective staff development trainings, as directed
• Provide Spanish language interpretation as required to assist clients in meeting care plan goals. Utilize provided translation services for clients in need of additional language support. Maintain a flexible schedule to allow for some weekend work as well as emergency coverage of shifts to meet the needs/demands of clients and related activities and events. Support and participate in activities and group events organized by HIV Department including but not limited to AIDS Walk, San Diego LGBT Pride Parade, and Clients’ Holiday Event
• Responsible for punching in daily and being compliant with SYH policies and procedures. Coordinate and post weekly schedules, advising Program Supervisor with any changes or time-off requests
• Perform other related activities as required or assigned by program supervisors, managers, or directors

Additional Duties and Responsibilities:

• Provide AIDS Drug Assistance Program (ADAP) and Ryan White enrollment as needed and ensure all eligible clients complete the ADAP enrollment process
• Increase relationships and communication with other San Ysidro Health programs and locations. Represent San Ysidro Health and Our Place to other organizations and community groups; network with other HIV and social support service providers
• Provide Spanish language interpretation as required to assist clients in meeting case plan
• Support and participate in activities and group events organized by HIV Department including but not limited to AIDS Walk, San Diego LGBT Pride Parade, and Clients’ Holiday Event
• Participate in all multi-disciplinary team meetings, staff meetings, and selective staff development trainings, as directed
• Maintain a flexible schedule to allow for some weekend work as well as emergency coverage of shifts to meet the needs/demands of clients and related activities and events
• Coordinate and post weekly schedules, advising Program Supervisor with any changes or time-off requests
• Responsible for punching in daily and being compliant with SYH policies and procedures
• Perform other related activities as required or assigned by program supervisors, managers, or directors

Job Requirements

Experience Required:

• Three (3) years of experience working in human or social services

Education Required:

• High School Diploma or GED equivalent

Verbal and Written Skills Required to Perform the Job:

• Bilingual English/Spanish required
• Excellent oral and written communication skills
• Communicate clearly and concisely, both orally and in writing

Technical Knowledge and Skills Required to Perform the Job:

• Knowledge of health and psychosocial issues concomitant to HIV disease
• Exercise tact, objectivity, sensitivity, strategy and judgment in dealing with a variety of people with a variety of co-occurring disorders
• Organize, set priorities and exercise sound independent judgment within areas of responsibility
• Establish and maintain effective working relationships with professional staff, clients, family members, and the public

Equipment Used:

• Proficient in Microsoft Office (Power point, Microsoft Word, Excel including pivot tables, Outlook), projectors, various software including ARIES, and Microsoft office

Working Conditions and Physical Requirements:

• Physical Activities standing, walking, sitting and lifting 25 lbs.
• May be required to travel to other facilities
• May be required to work evenings and/or weekends

Universal Requirements:

Pre-employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs. Compliance with all mandated vaccinations and all boosters is a term and condition of employment.