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Linkage to Care Coordinator I/II

Posted: 11/21/2021

To provide strengths-based Case Management services to people with HIV. Facilitates and monitors client service acquisition and progress with the goal of successful engagement in comprehensive HIV Care. 


  • Bachelor’s degree in Social Work, R.N., B.S.N, a related field or in a non-related field with 2 years’ experience in Case Management type services 
  • Master’s degree in Social Work, Nursing, or related field, with less than 2 years’ post graduate experience
  • HIV, hepatitis, and substance abuse prevention or service coordination experience with the target population preferred
  • Demonstrated experience serving a diverse population
  • Two years’ experience as a Case Manager I or
  • Bachelor’s degree in Social Work, R.N., B.S.N., or 2 years’ experience in Case Management type services; at least 3 years’ post graduate experience of which at least 2 years’ experience in HIV Case Management or
  • Master’s degree in Social Work, Nursing, or related field, with at least 2 years’ post graduate experience of which at least one year is in HIV Case Management
  • Active participation in at least one Clinic committee or Ryan White Planning Council Subcommittee
  • Participation in an ongoing quality improvement project/special project
  • Obtains and maintains state-issued rapid HIV/HCV testing method certification for provision of counseling, testing, and referral (CTR) services.
Diversity, Equity, and Inclusion
Definition: Provides culturally and gender affirming care and services to both patients and staff. Respects and values diversity in respect to race, gender, sexual orientation, primary language, and age, among others. Prioritizes equitable care and service in their work
Mission Orientation
Definition: Promotes health and wellness by providing quality care, access, research, and education to the underserved and all people in our community.
Definition: Works assigned hours and is punctual. Completes tasks and projects in a timely manner. Keeps commitments and is dependable. Exercises integrity in all aspects of their work. Demonstrates commitment, motivation, and dedication in reaching the highest standard of performance. 
Program and Quality Management
  • Maintains professional, well written, comprehensive, and accurate client record, documenting interactions with clients and/or on behalf of clients and according to program standards (SCOUT database)
  • Completes program reports and data requests in an accurate, thorough, and timely manner. This may include, but is not limited to, monthly program reports and data requests from regional and state levels
  • Participates in quality improvement projects as requested, including researching client data/trends, utilizing data measures to prioritize client contact, and streamlining internal procedures 
  • Assessment and Care Coordination
    • Completes comprehensive assessments and creates individualized service plans for all clients
    • Evaluates client eligibility for government-funded programs (i.e. Medicaid, Medicare, Social Security etc.), and provides referrals and follow up as appropriate
    • Makes referrals to community resources and services based on client need and eligibility, and coordinates follow-up care and decisions affecting the client. Confers with said referrals to explain agency policies, treatment philosophy, and programs; when sharing client information, maintain HIPAA and client confidentiality standards
  • Client Education and Advocacy
    • Provides education to clients on HIV, medication and medical appointment adherence, viral load and CD4 lab results, and risk reduction strategies; provides specific education to specialty clients (newly diagnosed or returning to medical care) regarding coping and acceptance of new diagnosis, navigation of health care system, and HIV education
    • Educates clients on process for submitting insurance and co-pay documentation and works closely with clients and necessary third-parties to maintain insurance coverage

  • Customer Service
    • Maintains regular contact with clients to provide ongoing assessment, support, intervention, and customer service.  This position is intensive case management and includes making weekly contact with clients for the first 6 weeks and timely follow-up with client plan of care (goal/service plan) as documented in client file (SCOUT Service Plan)
    • Serves as client advocate to ensure access to, and understanding of, needed services; this may include assisting clients in applying for government funded programs, connecting clients to legal resources, serving as client reference for service applications; and attending medical appointments to ensure client understanding of medical care and treatment regimen
  • Teamwork and Collaboration
    • Performs “on-call” duties and acts as team leader on scheduled days including coverage at KCHD, weekends and after end of business day (i.e. responding in person to testing sites as needed when paged for new diagnosis or return to care, providing education and support to clients upon page, triaging needs of presenting client and testing site, attending to client needs after business hours when paged)
    • Participates in community outreach events including counseling and testing, overview of Linkage to Care Program, and educational needs as requested. Events may include evening and weekend hours.
    • Operates as a team member of the KC CARE Health Center; supporting other staff members when needed 
    • Performs all duties as assigned by the Department Director or Senior Staff Members to support the operations of KC CARE and the HIV continuum of care programming
  • Communication
    • Collaborates with internal and external partners regarding client care and goals
    • Maintains professional, timely, and clear communications between team members and other staff members
    • Attends scheduled Kansas City Health Department Ryan White HIV Case Management meetings and other internal team meetings as scheduled by supervisor; and attends Comprehensive HIV Prevention and Care Planning Council monthly meetings on a rotating team schedule
  • Planning and Organizing
    • Enrolls/makes referrals for clients to enroll in the most comprehensive insurance plan available to them and assesses client eligibility for insurance premium and co-pay assistance
    • Participates in KC CARE’s HIV Multidisciplinary Team to ensure all client needs are being met
  • potential exposure to virus, disease, and infection from patients in working environment
  • while performing the duties of this job, the employee is regularly required to identify, communicate, and exchange information.
  • the employee regularly is required to move about the building.
  • position may be considered eligible for remote or hybrid (remote and in-office) work accommodation
  • expected to travel to community meetings, client homes, or other agencies
  • may encounter and provide care/support to people experiencing trauma and/or behavioral health conditions
  • employee may regularly have to lift up to twenty (20) pounds

Job Type: Full Time

Salary Range: $30,000 - 49,999