State of Florida
Location (4)
Fort Pierce, Florida
Salary
$36,000 / YEAR
Locations
This position provides medical case management to individuals infected and affected by HIV/AIDS within a four-county area, involving comprehensive needs assessments, individualized care plan development, and continuous monitoring of treatment adherence and service implementation. Responsibilities also include screening for various payer sources, maintaining accurate database records, and providing client education, advocacy, and linkage to necessary community services.
A minimum of one year of experience at a social service-related agency or in a social services work position is required, along with the ability to work independently, handle stress, and maintain client confidentiality. Candidates must possess knowledge of interviewing and communication techniques, be detail-oriented, and capable of making independent judgments.
09/24/2026 Total Compensation Estimator Tool 6 month advertisement This is a “pool” announcement, and applicants will not be considered after 6 months. This posting could be used to fill future vacancies This posting may fill multiple positions Job posting category: Open Competitive Your Specific Responsibilities: This position provides medical case management to persons infected and affected by HIV/AIDS within the four-county area of Indian River, Martin, Okeechobee, and St. Lucie Counties (area 15). This position provides proactive and inclusive case management activities through office or field visits according to the guidelines established by the Florida Department of Health Bureau of Communicable Diseases HIV/AIDS Section and the Area 15 HIV/AIDS Program Office. This position reports to the Operations Management Consultant II Completes comprehensive Needs Assessments of individuals presenting themselves for assistancethrough the agency. Face-to-face assessment and re-assessment (including assessment of adherence to treatment, adherence to appointments, and family planning needs): Comprehensive needs assessment describes in detail the client’s medical, physical, and psychosocial condition and needs. It identifies service needs that are addressed for the client.and by whom, service needs not provided for the client, barriers to care for the client, and services not adequately coordinated for the client. It also evaluates the client’s resources and strengths, including their social support network, which can be used during care planning. Needs Assessments indicate that medication and appointment adherence issues have been addressed. Completes acuity assessment at the time of the initial comprehensive needs assessment. The comprehensive needs assessment is completed within 30 days of the brief. Intake/enrollment screening to permit the initiation of case management activities, as well as to meet immediate needs and allow for a thorough collection of pertinent information.Develops an individualized care plan to address identified needs. Address individualized goals, objectives, needs, and barriers to care. Findings of the Needs Assessment must flow into the Plan of Care and be addressed in the case notes. Documentation must show that needs are being addressed in an ongoing manner. Re-evaluation at least every six months with adaptations as necessary according to acuity level over the life of the client. Completes acuity assessment at the time of the care plan update. Monitoring clients to assess the implementation and efficacy of the care plan, and ensuring continuity of care and no gaps in care. Care Plan Implementation, Client Contact, Monitoring, and Follow Up:Responsible for the implementation and oversight of the care plan. Completion of tasks listed in the care plan. The type and frequency of contact should be based on client acuity. Case managers follow up to determine delivery of services.Ensures that any applicable hierarchy of payer sources is used appropriately. Screens for Medicaid eligibility, PAC Waiver eligibility, Medicare A, B, and D eligibility. Verifies VA benefits. Determines whether client has private health insurance or could obtain private health insurance through an employer, referring to ADAP Premium Plus when appropriate. Ensures Ryan White services are consistently used as the payer of last resort. Updates all required information regarding payer source eligibility on his/her clients in the CAREWare and HMS Databases within three business days. Completes and maintains accurate documentation of all client-specific activities:Documentation including direct client interactions and roles undertaken on behalf of a client. Documentation includes written case notes and requires form scanning. Detailed case notes how client’s needs are being addressed, how barriers to meeting these needs are being overcome, and how client is progressing towards POC goals. Case notes, form scans and all required information on clients are entered in the CAREWare and HMS database within three business days. Documentation on inactive and closed cases are completed, thoroughly exploring all methods of client contact available and allowed referral to community resources where applicable and follow up with all providers of record.Counseling, Support, EducationMonitoring of HIV medication therapy to include education of the client concerning risks and side effects, and monitoring client adherence and tolerance of medications. Providing treatment adherence support. Reviewing and monitoring CD4 and viral load (VL) lab values to include making sure the most current CD4 and VL lab values are recorded in the client file/database. Educating clients about HIV, and its transmission and complications; and HIV risk reduction. Educating clients about insurance and entitlements and providing navigation and enrollment support. Client-specific advocacy (i.e., with a landlord, medical team, substance use counselor, etc.) Reviewing client utilization of services. Linkage, Referral, Patient Navigation, Retention in Care:Timely coordination and linkage of the client to appropriate agencies for services and activities required to assist the client in achieving the goals and objectives identified in their care plan. Facilitating linkage and re-engagement activities for clients who appear to be out of care. Provide linkages to agency, community and government services and monitor referral completion including ADAP, medication patients’ assistance programs (PAP), benefits/health coverage programs such as SSI, SSDI, Medicaid, Medicare, housing programs, etc. Coordinating, referring, and linking clients with additional services e.g., housing support, substance abuse and mental health treatment, AIDS Drug Assistance Program (ADAP), food services, etc. as needed; Authorizes for transportation for clients to receive medical services and other social aid services as needed. Networks with other departments including but not limited to Ryan White case management, HOPWA, prevention, DIS, TOPWA, HUG Me and providers to assure smooth transition of services and continuity of care.
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