Case Manager - Bilingual Spanish - HIV Prevention/PrEP

Bedford Stuyvesant Family Health Center

The Bedford-Stuyvesant Family Health Center (BSFHC) is a patient-centered, team based multi-specialty practice in central Brooklyn. BSFHC has been providing affordable, comprehensive, outpatient medical and dental services in an outpatient setting for over 40 years. As a Federally Qualified Health Center (FQHC), BSFHC serves all of the primary health care needs of families in the heart of North and Central Brooklyn. Our mission is to provide the most professional, courteous and highest quality health care, with dignity, to those we serve, especially the undeserved population, without regard for ability to pay.

This position joins the HIV Prevention Team to support activities to promote and improve the health for people at risk of HIV/AIDS in addition to people with HIV in the wider community. Case Managers will work on a project-specific basis to reach and engage the uninsured or out-of-care, especially immigrants and other hard-to-reach populations, as well as those in need of access to PrEP, HIV care, behavioral health, chronic disease management and referrals for services in the community. It is critical that Case Managers have the required level of skills and expertise to work independently to develop effective strategies for adherence counselling, support the management of high viral loads and improve retention rates among patients.

As a Case Manager on the HIV Prevention team, you will be responsible for patients along the status neutral continuum. A typical case management caseload will include PrEP, HIV and Hep C caseloads. About 25% of HIV patients are coinfected with Hepatitis C, which makes it essential to understand the biology, treatment and support services required to effectively support these patients.

Grant-funded: Contingent upon continuation of grant funding from year to year
Required fieldwork about 75% of the time and take mass transit to travel throughout New York City.

Duties and Responsibilities include but not limited to:
Case Management responsibilities:
  • Maintain a caseload that provides comprehensive service delivery to all patients.
  • Provide coordination and monitoring of all patients on PrEP for medical treatment and medication accessibility.
  • Provides coordination and monitoring of HIV/AIDS medical treatment.
  • Conduct rapid HIV testing to all persons (internally and in community settings) who are interested in PrEP and perform risk assessments for everyone who expresses a need to start taking PrEP as a medication to prevent HIV.
  • Conducts patient intakes, assessments, reassessment, and develops and monitor service plans activities.
  • Develops and monitors individualized patient care plans.
  • Participates in patient case conference, taking detail notes to include in the EMR system.
  • Conducts treatment adherence work with patients and follows up with patients' appointments to include making appointments for patients.
  • Update PrEP Database and Excel spreadsheet daily and as per needed based on PrEP Visits.
  • Conduct patient education sessions/risk assessment for patients who have been diagnosed with STIs (syphilis, chlamydia, trichomoniasis, Mpox, gonorrhea, HPV).
  • Experience entering clients' data into AIRS and other database systems.
  • Support the quality improvement activities, meeting and webinar.
  • Provides weekly report of encounters to Data Manager.
  • Complete all assessments, service planning and participate in case conferences with both internal and external stakeholders.
  • Work with colleagues and Community Support Liaisons to retain patients into care.
  • Optimize enabling services for patients and make appropriate referrals as needed.
  • Complete the palliative care screens for patients and other EMR/AIRS ticklers as needed.
  • Monitor clients in both the RAP and MCM Programs and work with Peer Navigators to empower clients lost to care.
  • Timely update of AIRS with relevant data including indicator ticklers.
  • Contribute and participate in case huddles, and case conferences, with appropriate level of documentation.
  • Work to organize the CAB meetings in collaboration with CAB president and other members designated by the CAB.
  • Collaborate and work alongside medical care teams to provide the most effective care strategies and treatment.
  • Submit timely and completed reports that reflect the nature of your work activities.
  • Contribute to QI activities and QI meetings to ensure the highest level of patient engagement and viral suppression rates.
  • Work with supervisor on any other duties that may be assigned.
Outreach activities responsibilities:
  • Market the services of the Center to patients and families with the intention to reaching people who are not engaged in care.
  • outreach-based marketing strategies and implementation plans to help the agency engage community residents in Bed-Stuy and Bushwick
  • Assist to develop strategies for reaching local populations who are most-at-risk for contracting HIV/AIDS,
  • Conduct HIV prevention-based presentations in the community as needed.
  • Represent and attend external QI meetings as directed by supervisor.
Service Delivery Site:
  • Provide services to any designated service delivery site.
  • Bachelor's degree or equivalent experience in public health, public administration, social work, psychology, biology or a related field
  • Fully Bilingual (Spanish/English)
  • Experience conducting community outreach
  • Ability to work in an affirming, fast-paced, high-energy environment
  • High level of accountability and initiative; needs to be a self-starter and value teamwork that supports the organization's growth.
Bi-lingual Spanish Speaking Candidates Preferred

Salary Range: $ 50,000 - $53,000

Benefits Overview: We offer attractive compensation with comprehensive benefits including: Medical, 401k Retirement Plan with discretionary Match, Free Life Insurance and Long-Term Disability, Transportation Plan, Generous Paid Vacations and Holidays.

Job Location
Brooklyn, New York, United States
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