JOB PURPOSE AND REPORTING STRUCTURE:

Under the direction of the Linkage To Care Manager and within the Community Services department the Linkage to Care Specialist provides intensive outreach and linkage to care  case management services to clients living with HIV that are newly diagnosed, recently released from incarceration, out of care or at risk of disengaging from HIV medical care.

Primary tasks include client assessment, service planning, referral to and coordination of care to HIV medical care and primary care providers, referral to and coordination of care to other health care providers including mental health care and community resources and benefit systems.

Work tasks will occur in clinic, hospital, office, client homes, and community based clinic settings. This position will be primarily housed at The Milwaukee Health Department Keenan Sexual Health Clinic and will work collaboratively with Partner Services. The majority of work tasks will occur outside of the office at community based health care settings or in other community settings.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Manage Referrals of people living with HIV that are newly diagnosed, recently released from incarceration, out of care or at risk of disengaging from HIV medical care.

Provide intensive case management including intake, assessment, service planning, referral and coordination of care to HIV medical care, other health care providers and community resources. Discharge planning. Maintain compliance with State of Wisconsin DHS Linkage To Care Practice Standards.

Actively link clients to HIV medical care providers.  Work with clients to identify barriers to HIV medical care engagement and assist clients in addressing barriers to HIV medical care. Work with clients to create formal and informal supports.

Provide support, referrals and care coordination related to medication access and management.

Engage in regular client consultation and staffings with supervisor and care team members.

Maintain professional and ethical boundaries with clients. Practice client confidentiality in all aspects of work as required by law and program policies.

Assist clients with applying/accessing and maintaining community benefits, medical insurance and other community resources including transportation, housing, food and basic needs.

Assess need for mental health and substance use treatment, provide referrals and appropriate follow up to clients.

Provide intensive HIV education to clients. Actively engage clients around increased knowledge of HIV, health literacy and health care navigation. Utilizes a harm-reduction framework.

Frequent collaboration with The Milwaukee Health Department, Partner Services, The State of Wisconsin HIV surveillance program, HIV medical providers/clinics and CTR sites.

Functions as part of the client’s interdisciplinary care team; coordinating care and regular communication with care team members at other health care organizations.

Proficient use of EMR (electronic medical record) and other client data management systems. Complete accurate, timely and professional documentation.

Complete/attend required Wisconsin DHS HIV/AIDS program trainings and meetings.

Follow and comply with all safety and work rules and regulations.  Maintain departmental housekeeping standards.

MARGINAL JOB FUNCTIONS:

Complete special projects as assigned, including outreach activities in the community.

Other duties as assigned.

QUALIFICATIONS:

To perform this job successfully, an individual must be able to perform each essential duty. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE:

Requires a Master’s degree in Social Work from a Social Work program accredited by The Council on Social Work Education.

A minimum of three years of social work practice in a health care setting.

Ability to manage multiple high acuity events at one time.

Strong interpersonal skills; experience in safety planning and de-escalation.

Ability to assess and intervene in crisis situations that may result in client harm to self or of harm to others in the community.

Experience working with racial/ethnic minorities, the LGBTQ community and people living with chronic and persistent mental health disorders is highly desired.

Social work clinical supervision will be available toward acquiring clinical hours.

WORK ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is frequently exposed to outside weather conditions. The employee frequently performs work-related travel.

The noise level in the work environment is moderate to quiet.

TYPICAL SCHEDULE:

Full time work schedule during core operational hours Monday through Friday. Occasional early morning or evening hours. Flexible work environment.

Outreach Community Health Centers offers a robust benefits package, including:

• ​​​​Generous Paid Time Off & 10 Paid Holidays
• Medical, Dental and Vision Insurance
• Employer Paid Short and Long-Term Disability Insurance
• Life, Dependent Life and AD&D Insurance
• Voluntary Term Life Insurance
• 401(k) Plan
• Employee Assistance Program (EAP)