Other duties & responsibilities applicable:
What we are looking for.
The Preventive Care Navigator is an integral team member who coordinates and ensures quality HIV and HIV prevention services in support of Settlement Health Primary Care HIV Prevention Program. They ensure that our patients who need a care team are given comprehensive, timely and appropriate services tailored to their medical and psychosocial needs and document in appropriate ways to ensure compliance with state and local agencies and funding agencies. The Preventive Care Navigator will work with the clinical teams to provide education and referral support services to patients/families affected by substance use disorders.
The Preventive Care Navigators primary focus is the coordination, collaboration as part of the care team, patient engagement and panel management of our patient population living with HIV (referred to as SFU internally) and our HIV prevention activities.
SFU Care Management Responsibilities:
- Coordinates the delivery of care management/clinical support services to patients whom are living with HIV or AIDS.
- Works closely with the HIV specialist, peer educators and other care team members to assess patient and programmatic needs to develop programmatic structure to meet those needs, including in areas of treatment adherence education, prevention education, support group, interdisciplinary meetings and general case management support services.
- Conducts intakes and psychosocial Assessments of patients newly diagnosed as HIV+, and assumes responsibility for ensuring that the initial serve plan is developed with the pt, to include psychosocial needs and referrals, health education and coordination of initial appointments with the Settlement health medical provider. Psychosocial Assessments are reviewed and renewed on a yearly basis thereafter and the service plan is updated as appropriate.
- Works collaboratively as part of the care team and works with the medical providers and patient to develop a comprehensive plan for medical treatment.
- Ensures that the patient understands their treatment plan, knows of all upcoming appointments, including specialty, medical and nutritional. Meets with patients, families, and/or significant others to facilitate carrying out of care plan. Discusses partner notification with patients.
- Coordinates with the care teams and follows up with pts that who have missed regular appointments for care of services. This includes monitoring visits, GYN exams, and assists them to overcome barriers of getting care.
- Provides comprehensive case management including application for HASA and ADAP/ADAP+, and other benefits; escorts if necessary, referral for legal, mental health, housing, substance abuse services; and coordination.
- Maintains and frequently updates SFU data registry to ensure compliance with the standards of care, state and local agencies and funding requirements.
- Takes lead in presenting SFU data and coordinating quarterly meetings to assess status of the SFU population and brainstorming targeted interventions to improve any areas of concern (ie viral load suppression).
- Participates in HIV Primary care QI process, assuming leadership where appropriate in the development and implementation of Quality Management.
HIV Prevention Care Management Responsibilities:
- Coordinates the delivery of Care Management/clinical support services and activities that support HIV prevention in primary care.
- Work collaboratively as part of the care team to identify and support the care of pts who are good candidates for PrEP (Pre-exposure prophylaxis).
- Assesses patient readiness to begin treatment and conducts care management assessment for all patients prescribed PrEP. Assumes responsibility for ensuring that an initial service plan is developed with the patient, to include psychosocial needs and referrals, health education, and coordination of initial appointments with the Settlement Health medical provider. Updates service plan as appropriate.
- Supports PrEP adherence by providing education, helping patients anticipate and manage side effects, ask about successes and challenges at follow up visits in a non-judgmental manner, help patients establish dosing routines that mesh with their work and social schedules and provides reminder systems and tools.
- Ensures that the patient: understands their treatment plan, knows of all upcoming appointments. Meets with patients, families, and/or significant others when appropriate to facilitate carrying out of care plan.
- Manages and monitors PrEP patient panel registry to ensure compliance with required appointments and adherence with medication and any other appropriate preventive care.
- Develops a comprehensive risk assessment tool focused on patients that have STI’s or engage in high risk behaviors and engages these patients by providing health education, assessment and referrals and collaborates with the patient on identifying and implementing risk reduction strategies.
- Is trained in and conducts HIV testing and counseling as needed to support HIV prevention and initiation of PrEP.
- Is a Certified Applications Counselor and assists patients in applying for insurance coverage to reduce financial barrier to PrEP initiation and ongoing adherence.
- Supervises Peer Educators who facilitates support group to provide treatment education, socializing and support opportunities for HIV positive patients.
SUD Focus Essential Duties & Responsibilities
- Implement screenings (such as SBIRT, AUDIT and DAST), in order to identify at risk patients with the goal of reducing and preventing related health consequences.
- Provide interventions for patients identified by the providers as struggling with Alcohol Use Disorder by providing referrals to the appropriate level of care.
- Provide adolescents and parents with education about early identification and prevention of substance abuse disorders.
- Expand evidence-based mental health and substance abuse prevention and education programs for patients, families, communities, and personnel to increase awareness of, patient access to, and patient retention in mental health and substance use disorder treatment programs.
- Act as a liaison to health care providers, community agencies and other staff to ensure patients access to services within SH as well as the community, and to address any barriers for the patient in accessing care.
Other duties & responsibilities applicable:
- Establishes and maintains linkages with social service agencies both internally and externally of East Harlem community that have the capability of meeting Settlement Health’s patient needs including those which offer Cobra Case Management.
- Documents all patient encounters appropriately in electronic medical records. This is done in a clear and comprehensive manner and in a timely fashion.
- Participates in all required organizational and team meetings
- Represents Settlement Health at appropriate East Harlem and citywide meetings and events as indicated by Director of Care Management.
Settlement Health.
We are located in the heart of East Harlem. Settlement Health has been part of the community since 1977 and we provide affordable, quality primary care health services.
What we offer.
Settlement Health offers an attractive compensation package which includes a 401K Retirement Plan, generous paid time off, flexible spending accounts, free life insurance, commuter benefit programs, discount programs and much more…
Job Type: Full-time
Pay: $55,000.00 - $60,000.00 per year
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Employee discount
- Flexible spending account
- Health insurance
- Life insurance
- Paid time off
- Retirement plan
- Vision insurance
Schedule:
Work setting:
Experience:
- Completion of Peer Education training program: 2 years (Required)
Work Location: In person