Nurse Case Manager - Outreach

Job Summary

We are seeking an HIV Nurse Case Manager who is interested in a unique opportunity to work on a dynamic, multidisciplinary HIV primary care team that has been nationally recognized as a model of excellence. Alongside medical providers, case managers, social workers, behavioral health team members and other HIV nurses, you will provide high-quality nursing care to patients consistent with the philosophy of patient centeredness, non-judgement, and team-based care.

You will serve in a key clinical role to the care team with primary responsibilities of HIV and other chronic disease management, care coordination, advice/triage needs for the team’s patients, and ensuring excellent communication of the care plan across team members. In this role, you will conduct clinical nursing assessments and triage for team patients during routine and urgent medical visits in the outpatient clinic, as well as during outreach visits to shelters, drop‑in centers, street venues and patients’ homes.

You will also provide care coordination, medication adherence support, health education, and behavioral risk reduction counseling for HIV primary care patients. This role offers a unique opportunity to promote linkage and retention to HIV primary care, with the aim of supporting people experiencing homelessness and living with HIV to achieve and sustain health and wellness.

Currently offering a $4,000 sign‑on bonus.

The position is funded until the end of March 2028 with possibility for renewal. If this funding is not renewed, the position will end March 31, 2028.

Hours: Monday‑Friday, 8:00 am‑5:30 pm – full‑time or part‑time schedule possible.

Union: No

Patient Facing: Yes

• Provides outpatient primary care nursing including medical assessments and triage services for HIV team patients coming in for same‑day or scheduled visits; conducts virtual, telephonic, or in‑person nurse assessment and triage to assess the severity of the patient’s health concerns using approved protocols and resources to advise appropriately. Documents patient information accurately and in a timely manner in the EHR.
• Implements the patient‑centered plan of care, evaluates outcomes, and regularly communicates the plan of care, patient status, and progress toward goals with the patient and care team members; conducts comprehensive intake assessments for new HIV team patients.
• Administers vaccines, injectable medications, and provides wound assessment and wound care as indicated; provides medication adherence assessments and counseling. Provides directly observed therapy when indicated with support of outreach team members.
• Coordinates care with integrated HIV team behavioral health staff. Along with other team members, visits patients at shelters and other outreach sites to provide nursing care and care coordination services and identify barriers to medication adherence and engagement in care.
• Provides chronic disease management support for HIV as well as other common co‑morbid medical conditions such as diabetes and hypertension. Identifies any structural barriers patients face in accessing medical care and adhering to HIV medications, and works with the interdisciplinary team to address those barriers (e.g., housing, transportation, drug treatment, food, clothing, benefits, etc.).
• Assists medical providers in coordinating follow up related to the provision of medication (such as buprenorphine and naltrexone) for opioid use disorder and other substance use disorders. Coordinates preventative services for HIV team patients including, but not limited to, education, preventative medications, vaccinations, testing, and referrals.
• Promotes a compassionate and therapeutic environment that is responsive to the unique patient population and extends to members of the care team; demonstrates initiative and commitment to continuously improve services and processes that positively impact patient care and organizational goals. Participates in training and orientation of new nursing staff as directed by Supervisors.
• Exhibits a positive attitude with patients and establishes professional and respectful relationships with the internal and external…