RAP Specialist Case Manager

The Bedford-Stuyvesant Family Health Center (BSFHC) is a patient-centered, team based multi-specialty practice in central Brooklyn. BSFHC has been providing affordable, comprehensive, outpatient medical and dental services in an outpatient setting for over 40 years. As a Federally Qualified Health Center (FQHC), BSFHC serves all of the primary health care needs of families in the heart of North and Central Brooklyn.

Our mission is to provide the most professional, courteous and highest quality health care, with dignity, to those we serve, especially the undeserved population, without regard for ability to pay.

The RAP Specialist Case Manager supports activities to promote and improve the health for people at risk of HIV/AIDS in addition to people with HIV in the wider community. Case Managers will work on a project-specific basis to reach and engage the uninsured or out-of-care, especially immigrants and other hard-to-reach populations, as well as those in need of access to PrEP, HIV care, behavioral health, chronic disease management and referrals for services in the community.

It is critical that Case Managers have the required level of skills and expertise to work independently to develop effective strategies for adherence counseling, support the management of high viral loads and improve retention rates among patients.

Grant-funded :
Contingent upon continuation of grant funding from year to year. Required fieldwork about 75% of the time and take mass transit to travel throughout New York City.

• Provide coordination and monitoring of HIV/AIDS medical treatment.
• Conduct patient intakes, assessments, reassessment, and development of service plans activities.
• Develop and monitor individualized patient care plans addressing medical, psychosocial, and behavioral health needs.
• Coordinate referrals and follow-up for supportive services such as housing, food assistance, employment, and transportation.
• Maintain ongoing client contact to assess progress, barriers, and promote self-sufficiency.

• Conducts treatment adherence work with patients and follows up with patients’ appointments to include making appointments for patients.
• Educate clients on HIV treatment adherence, viral suppression, and prevention strategies including PrEP and PEP.
• Empower clients to take an active role in their health and treatment decisions.
• Collaborate with healthcare providers to address adherence challenges and identify appropriate interventions.

• Experience entering clients’ data into AIRS System.
• Support the eHIVQUAL data entry attends meeting and/or participates in Webinar when required Provides weekly report of encounters to Data Manager.
• Complete all assessments, service planning and participate in case conferences with both internal and external stakeholders.
• Monitor clients in both Tier 1 and 2 of the RAP Program and work with Peer Navigators to empower clients lost to care.
• Timely update of AIRS with relevant data including indicator ticklers.
• Complete the palliative care screens for patients and other EMR/AIRS ticklers as needed.
• Contribute and participate in case huddles, and case conferences, with appropriate level of documentation.
• Follow through implementing project-specific activities such as enrolling patients in the DRISP HIV Undetectable Program.

• Work to organize the CAB meetings in collaboration with CAB president and other members designated by the CAB.
• Contribute to QI activities and QI meetings to ensure the highest level of patient engagement and viral suppression rates.
• Work with supervisor on any other duties that may be assigned.

• Market the services of the Center to patients and families with the intention to reaching people who are not engaged in care.
• Outreach-based marketing strategies and implementation plans to help the agency engage community residents in Bed-Stuy and Bushwick
• Assist in developing strategies for reaching local populations who are most-at-risk for contracting HIV/AIDS,
• Conduct HIV…