To provide integrated care for the target population including working with doctor, nurses, dentist, psychiatrist, case manager, social workers, activity directors, etc., to develop best plan for care of patient and monitor implementation of the plan and progress of patient and adjust plan as required. Manage patient navigation through external and internal systems.
Will follow role assignments that are in alignment with the Patient Centered Medical Home Standards, and participate in all Patient Centered Medical Home efforts.
Serve as a liaison for patient with both external and internal systems to assure continuity of care upon referral, and that all needed services are assessed and provided.
Work with internal and external resources to preserve dignity and sustain quality of life of all patients.
Meet and assess patients upon referral.
Work with doctor, nurses, dentist, psychiatrist, social workers, activity directors, etc. to develop best plan of care of patient and monitor implementation of the plan and progress of patient and adjust plan as required.
Ongoing assessment and planning with and/or on behalf of clients.
Provide health education for community facilities and other professionals.
Organize necessary information including personal, legal, medical, financial, SS/Medicare/Medicaid, care provider and logs for patient in a notebook and central file and keep it current.
Build relationships with other supplemental agencies who serve the patient.
Obtain all required certifications within established national, state and agency deadlines.
May be required to work at different site locations or ocassional Saturday or evening hours.
Bachelor’s Degree preferred (BSN or other related field in a behavioral science, social service or health-related area) and/or formal training in the field of HIV/AIDS.
Prevention counseling and/or education through an accredited program or institution.
Completion of an accredited course in HIV/AIDS counseling, prevention, and/or education and certification in the field of AIDS/HIV infection counseling, prevention and/or education
About NEAR NORTH HEALTH SERVICE CORPORATION
Near North Health Service Corporation is an Equal Opportunity Employer. The Mission of Near North Health Service Corporation (NNHSC) is to provide access to high quality health care and to improve the health and well-being of the diverse populations and communities we serve. We are a culturally sensitive, patient centered community health center that empowers individuals through education and health prevention, regardless of one’s ability to pay.