Infectious Disease Care Coordinator

SUMMARY:
Support and promote LACHC’s mission to show God’s love by providing quality, comprehensive healthcare to the homeless and underserved in all job duties and responsibilities. The Care Coordinator will encourage testing for HIV and Hepatitis C at our clinic and street medicine sites. The care coordinator will also conduct outreach to HIV and HCV patients to increase their linkage to further care. In addition, the coordinator will ensure testing and linkage for those tested for HIV both in clinic and street medicine settings. The coordinator will work with HIV and Hepatitis C-positive patients to help coordinate the physical health, behavioral health, and community-based long-term services that they need. The Care Coordinator is accountable for facilitating access to the above-mentioned services and coordinating with entities that authorize services and pharmaceutical therapies as necessary to support the achievement of individualized health action goals. The coordinator is also responsible for managing all STI patient registries, reviewing weekly STI testing data, ensuring accuracy of the testing data prepared by other care coordinators and submitting monthly and quarterly reports to fulfill grant requirements.

ESSENTIAL DUTIES and RESPONSIBILITIES include:

• Ensure staff compliance with departmental and organizational policies, procedures, and expectations.
• Monitor compliance for grant requirements, including completion of comprehensive assessment(s) and grant reports.
• Ensure care plan documentation and care coordination data accurately recorded in HER.
• Create health education tools and courses to bolster training materials for the department, colleagues, and patients.
• Assist in management of department budget and funds, along with grant budgets and spending.
• Utilize Trauma-Informed Care, Motivational Interviewing, and Harm Reduction strategies, including certification is Narcan administration, to clinic patients.
• Provide direct patient care coordination services to patients in clinic and in street medicine settings
• Use evidenced-based outreach strategies to locate clients and link patients into care.
• Interview and assess patients to identify social, emotional, and economic factors which may interfere with attaining Hep C, HIV care.
• Promote self-management skills so the patient is better able to engage with health and service providers and support the achievement of self-directed, individualized health goals to attain recovery, improve functional or health status, or prevent slow declines in functioning.
• Ensure that patients are knowledgeable about their conditions with the overall goal of improving the patients’ linkage to care and adherence to treatment by providing culturally appropriate information that meets health literacy standards.
• Collaborate with clinical staff and patients to identify barriers to linkage to care, such as substance use disorders, homelessness, and severe mental illness.
• Provide health education on topics such as nutrition, food, drug use, harm reduction, etc. Help patients set goals and solve problems for improved self-management.
• Monitor medication use and treatment adherence by patients
• Coordinate specialty follow-up appointments, diagnostic imaging, lab testing, and follow-up with other needed services and supports.
• Coordinate with authorizing and prescribing entities, such as Medi-cal, Health Maintenance Organizations (HMOs), and specialty pharmacies to help patients apply and get approved for Hep C and HIV pharmaceutical treatment.
• Work with providers to ensure all necessary labs and diagnostic imaging are completed to identify potential Hep C patients and submit Prior Authorization applications (for HCV medications) to assigned insurance companies.
• Utilize eClinical Works to gather and input required patient data (i.e. mode of transmission, previous test results) for Monthly and Quarterly finance reports.
• Ensure completion and proper submission of monthly testing estimates and of quarterly Reports.
• Maintain a HIPAA- compliant registry for all patients testing positive for Hepatitis C and HIV.
• Participate in case conferences to ensure that the patients’ care is continuous and integrated among all service providers.
• Manage HIV registry and coordinate PrEP, PEP and long-acting HIV treatment injections.
• Other duties as assigned.

Street Medicine Tasks:

• Embeds with street medicine teams to provide navigation for high-risk patients to encourage HIV screening and PrEP.
• Embeds with street medicine teams to provide navigation for patients with HIV such as linkage to care and medication access.
• Accompany unsheltered patients with HIV to in-clinic appointments and support telehealth visits as applicable.
• Order and track rapid HIV screening by street teams.
• Analyze HIV prevention data for street teams (linkage to care, positivity data from HIV screening on street teams, PrEP prescribing).
• Collaborate with street medicine staff and patients to identify barriers to linkage to care, such as substance abuse, homelessness, and severe mental illness.
• Coordinate specialty follow-up appointments, diagnostic imaging, lab testing, and follow-up with other needed services and supports when seen on street medicine team.
• Create a HIPAA- compliant reminder system for contacting patients testing positive for HIV on street medicine teams to assist with the assessment of risk factors, prevention of transmission, and linkage to ongoing care.
• Collaborate closely with Street Medicine Lead Provider through monthly meetings.
• Ensure medication access for PrEP on street medicine teams.
• Manage database, patient registry and producing monthly and quarterly reports on testing, linkage to care and PrEP prescribing with street medicine focus.
• Facilitate primary care provider (PCP) changes, insurance enrollment for those who are eligible through street medicine teams.
• Create and provide educational materials on PrEP for unsheltered people experiencing homelessness.
• Facilitate timely access to PrEP medications either through LACHC’s pharmacy or other methods for unsheltered patients to obtain PrEP medications.
• Provide information to patients on ADAP pharmacy enrollment.
• Manage in-house medication supply for PrEP and HIV quick start medications for mobile van.
• Manage harm reduction supplies for patients seen by mobile van.
• Facilitate transport for patients to attend medical appointments.
• Create and manage incentive inventory for patients.
• Manage harm reduction supplies for patients.
• Other duties as assigned.

QUALIFICATIONS:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• CPR Certification required.
• Bilingual Spanish preferred.
• Experience with data entry preferred.

EDUCATION and/or EXPERIENCE:

• Bachelor’s degree from a four-year college or university preferred.
• Prior experience in the health care setting is preferred.
• Prior experience working with the homeless, substance using, or chronically mentally ill individuals preferred.

COMPUTER KNOWLEDGE: Experience with Microsoft Word, Microsoft Access, Microsoft Excel, and eClinicalWorks preferred.

LANGUAGE SKILLS:

• Familiarity with medical terms and operations of clinics useful.
• Proficiency in English required, Bi-lingual/ Bi-literal Spanish preferred.

MATHEMATICAL SKILLS: Ability to calculate figures and amounts such as totals, proportions and percentages.

REASONING ABILITY:

• Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
• Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

PHYSICAL DEMANDS:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit and talk or hear. The employee frequently is required to use hands to finger, handle, or feel. The employee is occasionally required to stand; walk; reach with hands and arms; climb or balance; and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus.

WORK ENVIRONMENT:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORK STATUS:
Full-time, Regular, non-exempt position with Medical, Dental, Vision and 403B Retirement Plan with employer match. Equal Opportunity Employer. We will consider candidates with criminal history.

About Los Angeles Christian Health Centers:

Los Angeles Christian Health Centers opened in 1995 with a handful of staff but a big vision to render hope and healing through healthcare to the thousands of homeless and low-income residents living in Los Angeles County. Today, 120 staff members serve the County’s most vulnerable populations from our two full-time health centers in Skid Row and Boyle Heights. We also provide comprehensive medical care at our 10 part-time satellite clinics hosted by our community partners throughout Downtown Los Angeles and Watts.