HIV Prevention & Education Coordinator

HIV Prevention & Education Coordinator

All sites / On-site

Full-time / Monday - Friday

Position Overview:

As a member of the interdisciplinary care team, this position is responsible for providing administrative and provider support in the delivery of high-quality, patient-centered health care services for individuals living with HIV ensuring coordinated and comprehensive care across clinical disciplines. DVCH refers to patients living with HIV "Special Program" patients.

This position provides care coordination and administrative support for patients living with HIV, with special attention to vulnerable populations who may experience barriers to care due to residence, health status, age, personal characteristics, communication challenges, chronic illnesses and comorbidities, substance use disorders, high emergency department utilization, developmental status, or financial circumstances. Working as part of an interdisciplinary team, the position collaborates closely with pharmacists, LPNs, clinicians, behavioral health providers, and other healthcare professionals to coordinate comprehensive, high-quality, patient-centered care. Travel between health centers is required.

Summary of What You'll Do:

• Partner with healthcare providers to develop and implement comprehensive care plans that include screening, assessment, referrals, monitoring, and patient advocacy.
• Assist the care team in executing individualized care plans with active patient participation, utilizing networks, referrals, follow-ups, and coordination across various service settings including medical, social, correctional, and vocational services.
• Facilitate transitions of care, including after hospital discharges and visits to other medical providers, along with social history assessments such as substance use. Obtain necessary medical reports from other providers to ensure smooth transitions.
• Work with patients and their families to set self-management goals and offer coaching on behavioral changes based on practice protocols.
• Refer patients to in-house and external resources like OBGYN, social work, and dental services as per COE guidelines. Supports patients in connecting them to Medical Case Management services and facilitates Special Program Benefits Program applications for patients in need of applying.
• Educate patients on health topics and arrange specialty visits to improve health outcomes. Assists with developing and maintaining systems for care management of patients involved in medication and lab monitoring adherence.
• Completes intake for newly diagnosed or returning to care patients and ensure the immediate start of ART.
• Generate clinical reports using population health management software to identify eligible patients for outreach.
• Track and report individual and aggregate metrics in line with COE guidelines, using DHS-provided Care Management Report tracking sheets, and submit documentation to DHS to demonstrate the achievement of COE goals and benchmarks.
• Organize and participate in community health fair events to attract and enroll community members and raise awareness of HIV, PrEP, post-exposure prophylaxis (PEP), and HIV prevention strategies.
• Completes other duties as requested by the Care Coordination leadership.