Westchester Medical Center Advanced Physician Services, P.C.
Email Alexis Sanchez, Practice Manager for ALLY Care Center
Title: Retention Adherence Specialist
Job Code: A1056
Reports To: Practice Supervisor
Department: Outpatient – Ally Care Center
Identifies clients appropriate for the Retention and Adherence Program (RAP) based on eligibility criteria, including but not limited to the following:
- BIPOC, LQBTQIAA+, or other communities experiencing disparate HIV outcomes o Newly diagnosed with HIV
- Out-of-care or not regularly engaged in care
- Not virally suppressed (determined by most recent viral load test within 6 months prior to enrollment)
- Not enrolled in another case management program at the agency.
- Enrolls eligible clients in RAP program, creates a care plan individualized to the client’s needs, and updates this care plan every 6 months. Similarly, performs an initial assessment of client and re-assesses client every 6 months.
- Assists patients by acting as an advocate and navigator, promoting clean communication among care team and treating clinicians.
- Assists patients with understanding their medical diagnoses, treatment options and achieving best outcomes.
- Serves to directly communicate emergent information to clinicians and discuss/address needed lifestyle modifications
- Assesses, identifies and addresses social determinants of health for people living with HIV ∙ Assists with scheduling and obtaining authorizations for diagnostic testing, services, medications and transportation.
- Coordinate continuity of patient care when acuity level changes including the process of hospital admission and discharge, ER visits, home referral services and therapy.
- Participates as active team member for data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to the RAP program.
- Manages high risk patient care, including management of patient with multiple co-morbidities or high risk readmission to a hospital setting.
- Evaluates clinical care, utilization of resources, and development of new clinical tools, forms and procedures.
- Participates in identifying, managing and evaluating a Quality Improvement project on an annual basis
- Experience with electronic medical records.
- 2-5 years’ experience in a medical office or clinical setting
- Medical, Medical Record, Patient Advisory, Social Worker or science background preferred. ∙ Experience in medical case management preferred.
- Bachelor’s Degree or higher
License, Certification and Registration: N/A
- Team player that can follow a system and protocol to achieve a common goal. ∙ Highly organized and well-developed oral and written communication skills ∙ Demonstrates sound judgment, decision-making and problem solving skills
- Able to maintain confidentiality in accordance with practice, State and Federal regulations ∙ Ability to communicate/outreach to other community health care organizations and personnel.