Linkage to Care Specialist at Total Health Care

Job Summary 

Reporting
to the Linkage to Care Specialist Supervisor, the Linkage to Care Specialist is
responsible for identifying HIV-positive individuals as well as persons at
greater risk of acquiring HIV and facilitating linkage/re-engagement into
medical and supportive services as appropriate. Specifically, the Linkage to
Care Specialist is responsible for: 1) Providing HIV and Hepatitis C counseling,
testing,&  referral services and HIV
prevention health education to individuals in the community; 2) Identifying
individuals who are not engaged in medical care and assisting them in getting
linked/re-engaged into services; 3) Assessing and documenting eligibility for
Ryan White services, and referring individuals who are un-/under-insured
immediately to insurance/entitlement programs; 4) Developing strategies to
remove patients’ identified barriers to care; 5) Using proven behavioral
strategies to enhance motivation and willingness to participate in medical care
and supportive services; and 6) Monitoring the patient and providing support
and referrals as appropriate up to and including the second kept HIV medical
appointment.  

Linkage
to Care Specialists are assigned to a variety of venues that include medical
centers, substance abuse programs, hospitals, correctional facilities,
shelters, transitional housing, churches, LGBT community events, etc.  

Contacts and interactions vary and may involve multiple
constituencies such as direct interaction with THC’s executive management,
community organizers, the general public, THC’s patients, physicians,
colleagues, assigned staff, vendors, contractors and consultants for the
purpose of providing and exchanging information. 

Example of Essential
Job Functions  

· Establishes relationships with providers and key personnel throughout
the system of care, as well as with outside agencies in order to provide rapid
testing.  

· Provides on-site Rapid HIV and Hepatitis C testing in the community and
at Total Health Care sites, as needed. 

· Refers any positive
results to the Maryland Department of Health as required by law. 

· Provides
Pre/Post-test counseling for any HIV positive and Hepatitis C positive individual.
Completes necessary documentation of test results and services provided as
required by funders and applicable laws.  

· Performs a comprehensive
assessment to all HIV-positive clients identified/referred to identify medical
and psychosocial needs; barriers to care; understanding of HIV disease; and
understanding and knowledge of available Ryan White services and resources. 

· Develops and
implements an individual intervention plan to all HIV-positive clients
identified/referred that addresses needs and barriers identified in the
comprehensive assessment. Identifies linkage to appropriate services and
resources, whether internal or external. 

· Provides referrals to
medical and psychosocial support services to any individual encountered in the
community during a community event, including persons who are HIV-positive or
HIV-negative. 

· Demonstrates
competency in the delivery of behavioral change models (e.g. Harm Reduction,
Motivational Interviewing, Stages of Change, etc.). 

· Demonstrates
competency in speaking with individuals regarding HIV prevention strategies,
including PrEP/nPEP, U=U, Treatment as Prevention, etc. 

· Communicates with
patients by phone, mail, and community and home visits as needed.  

· Works as part of the multi-disciplinary team to provide tools and
strategies using a patient-centered approach to support individuals being
tested and linked to care. Attends weekly multi-disciplinary care team
meetings. 

· Attends and actively participates
in all required staff meetings, trainings, conferences, and supervision.  

· Participates in the
coordination and implementation of special events such as health fairs, HIV testing
day events, holiday campaigns, corporate sponsorships and other outreach
activities. 

· Coordinates and
facilitates educational groups at various venues. 

· Prepares and processes forms, spreadsheets, and reports to
appropriately document activities and services rendered. Collects and forwards
feedback on program services and community activities to the Linkage to Care Supervisor. 

· Demonstrates
awareness of program and grant goals, including their role in helping the
program to meet its deliverables. 

· Establishes and
maintain relationships with Total Health Care providers and staff, as well as
community agencies in order to connect patients to services.  

· Gathers patient data
and clinical information to enter data into the Practice Management System, Electronic
Medical Record and CAREware reporting system. 

· Schedules medical and other appointments on behalf of patients as
needed.  

· Gathers and documents attempts to gather program eligibility
information. 

· Demonstrates flexibility and is able to work in a changing
environment with a positive perspective.  

· Adheres to all Total
Health Care Human Resources Policy & Procedures, including but not limited
to maintaining a positive attitude, appropriate dress, timeliness and
attendance, and maintaining professionalism toward other Total Health Care
staff, patients, community partners, and individuals in the community. 

· Ensures personal
social media does not conflict with one’s ability to maintain respect in the
Total Health Care community. 

· Travel is required. 

· Other duties as
assigned. 

Minimum Education,
Training and Experience Required 

· High
School Diploma required  

· Rapid
HIV certification preferred.    

· Rapid
Hepatitis C training preferred   

· Certified
Phlebotomy preferred 

· Experience
in working in the HIV community in Baltimore is preferred 

Required Knowledge,
Skills and Abilities
Knowledge
of HIV disease, including prevention strategies, treatment options, and
available services in the community. Ability to present information to large
groups of individuals during community events. Ability to develop and maintain relationships,
and build credibility and trust in the community. Excellent customer service,
communication, and interpersonal skills. Ability to multi-task and prioritize
as appropriate. Ability to plan and organize work load to meet personal, team,
and department goals.  

Licenses and Certifications 

Certification in Rapid HIV Counseling and
Testing in Maryland 

Phlebotomy Certification preferred