Case Manager

The Housing Case Manager will be responsible for working with individuals who have been enrolled in AID Atlanta’s TBRA program or applying for financial assistance. This case manager will assist individuals with achieving their housing plans during their enrollment period on TBRA.

The Housing Case Manager works with members to remove barriers to HIV/AIDS medical care by facilitating a collaborative process that identifies members’ needs, a plan to address those needs, and continuous follow-up to ensure that members obtain the necessary services that help them to maintain adherence to medical care. The Housing Case Manager also coordinates with other service providers through a comprehensive and active referral process to link HIV+ individuals into appropriate services and care.

• Provide direct service coordination and support to people living with HIV/AIDS
• Provide Case Management services to members on a walk-in, scheduled, and on-call basis
• Manage caseload of up to 75 members
• Conduct initial comprehensive assessment and intake for eligible members
• Collaboratively develop and implement Individualized Service Plans (ISP) for each member on caseload, including conducting ISP updates every 6 months for each member
• Assess and evaluate member’s initial needs through the EMA screening tool
• Educate members about Case Management, and policies (Grievance, HIPPA, Member’sRights and Responsibilities) and other agency program policies to ensure member hasclear expectations of services
• Provide regular monthly (or more) contact with members to follow up on treatment plangoals and provide intervention as needed
• Advocate and mediate on member’s behalf to decrease or eliminate barriers to case
• Educate members about the importance of participating in medical care and ensure that members have full access to primary medical care
• Assess and Educate members about the importance of medication and medical adherence to improve member’s clinical outcome
• Assess and educate members about harm reduction, prevention, and other HIV related sexual transmitted infections (STIs).
• Conduct home and hospital visits, accompanying members to appointments as needed.
• Organize and facilitate new member orientation to ensure members have a clear understanding of how Case Management can be utilized beneficially
• Assess, verify and maintain records of a member’s eligibility for Case Management and various entitlement programs
• Document all interactions with or on behalf of a member within 72 hours
• Assess, collect, and maintain accurate member information and records in a confidential manner
• Complete monthly reporting to ensure accurate programmatic reporting (based on position/site assigned)
• Provide active referrals and application assistance and support to members
• Educate members about various community resources and programs to increase their knowledge of appropriate referrals
• Collaborate with physicians, nurses, and other clinical staff in the development and execution of member’s plan of care
• Attend monthly interdisciplinary meetings with medical providers (based on site)
• Maintain up-to-date resources of community services
• Participate in and volunteer for intra and interdepartmental activities/events across the agency (i.e. AIDS Walk fundraising. AIDS 101 participation, HIV testing and counseling, The Women’s Events, Prevent Blindness, etc. etc.
• Communicate regularly with staff about changes, updates, and improvements in service delivery issues or other agency related issues that directly or indirectly impact staff and/or members
• Attend agency, local, state, and national meetings, conferences, or workshops as needed or required
• Adhere to policies and procedures for AID Atlanta and other off-site programs to ensure…