Case Manager (Full-Time, 35-40 hours a week)

Required minimum Case Management staffing and duties:

Full Time Equivalent (FTE) Case Manager to:

• Engage the client not in care or sporadically in care. Employ skill techniques to actively support clients in activities that improve their health outcomes resulting in sustained viral load suppression;
• Conduct multidisciplinary case conferences and coordinate services and referrals with service and clinical providers that facilitate a client's engagement and retention in care;
• Address and remove barriers to enable client access to all necessary components of health care, including mental health and substance abuse services;
• Negotiate and advocate on behalf of clients for services that support self‐sufficiency and self-management;
• Develop health education curricula and activities specific to the TGNC communities;
• Identify needed and appropriate health education services for clients;
• Facilitate group and individual health education sessions;
• Work with the Peer Navigators to engage clients into care and treatment and support services.

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Peer Navigator (Part-Time, 20-25 hours a week)

The Peer Navigator will be appropriately trained and supervised to ensure that they are culturally competent and understand the goals and objectives that are being worked on in each case, especially when working with TGNC clients.  Each peer encounter with or on behalf of a client will be documented in a progress note and kept in chronological order in the client chart. Progress notes must focus on specific service plan goals, the problem or issue presented, the intervention that addressed it, the agreed upon follow‐up action to be taken, and the date for the next encounter. All attempts at contact with the client, family members and providers must also be documented, regardless of whether the attempt at contact was successful.

Required minimum Peer Navigator staffing and duties:

• Conduct outreach and engagement efforts to engage and retain clients in care;
• Assist clients in self‐advocacy and self‐management;
• Accompany clients on clinical and supportive service appointments;
• Assist Case Managers during some interventions;
• Assist the Health Educator during educational sessions.