Medical Case Manager HIV Care Coordination Hybrid Remote

Southwest Care Center employees can answer yes to these 3 questions:

• Do you want to make a difference?
• Do you believe everyone is entitled to quality healthcare?
• Do you desire to serve the underserved in your community?

For over 25 years, Southwest Care Center has been providing exceptional healthcare to the communities of Santa Fe and Albuquerque, NM. We are a non‑profit, FQHC‑LAL providing medical, behavioral health, case management, community outreach, diabetes education, and pharmacy services. We are proud to offer gender equity medicine, syringe exchange, and HIV/Hep C treatment, testing and other services within our communities.

Southwest Care Center is currently seeking a full‑time Medical Case Manager for our Santa Fe & Albuquerque clinics. This is a hybrid remote position, with the opportunity to work two days in clinic and three days remote. Candidate can be located in local area (Santa Fe or Albuquerque), but must be able to work in the Santa Fe clinic.

• Complete an intake with people living with HIV/AIDS interested in case management services; assess client‑specific information, barriers to care, and urgent needs.
• Work with peers and team members to orient the client/patient to the organization with a site tour, overview of available resources, and introductions to the treatment team, wrap‑around teams, and others.
• Meet with clients/patients to complete additional intake paperwork, authorizations, consents based upon desired services, etc.
• Provide client/patient with linkage to an insurance assister if needed, obtain required documentation, and assist with applications for medication assistance or ADAP as needed.
• Promote client/patient access to internal agency services including, but not limited to support groups, housing services, food programs, behavioral wellness, substance use treatment, and medical care.
• Be responsible and accountable for coordinating all aspects of client/patient care as listed on the service plan.
• Provide medical and non‑medical case management for enrolled clients/patients with the specific goals of achieving and maintaining viral load suppression.
• Schedule client/patient for appointments with required staff at SCC, identify available community‑based resources, and actively manage appropriate referrals, access, engagement, follow‑up, and coordination of services identified on the service plan.
• Conduct engagement services (including hospital visits, reminder phone calls, transportation, etc.) to increase the likelihood that clients/patients will attend appointments at SCC and will follow up regarding missed appointments.
• Conduct assessments, re‑assessments, case conferences, and service plan development with the client/patient and multidisciplinary team to reduce barriers to retention and adherence.
• Ensure that all client/patient interactions are documented in the client/patient electronic health record and e2NM within the designated time frame.
• Be responsible for contacting and tracking clients/patients who are not virally suppressed and lost to care.
• Coordinate case conferences/communication to address client/patient needs.
• Ensure a case conference/communication with the treatment team for all clients/patients who are lost to care.
• Based on outcomes of the case conferences/communication, link clients/patients to services such as the Treatment Adherence Program, Behavioral Wellness, partner notification, health education, housing, transportation assistance, etc.
• Have the ability and commitment to respect and support inclusiveness and diversity, including individuals of diverse backgrounds, cultures, races, ages, sexual orientations, gender identities or expressions, transgender experiences, opinions, etc.
• Demonstrate commitment to SCC’s behaviors and business impacts and model them in the organization.
• Maintain the confidentiality of all client/patient, employee protected, and proprietary information.
• Be accountable for meeting the performance standards of their department and must participate as requested in compliance audits, process improvement, and quality improvement plans.
• Ensure routine and appropriate documentation in the electronic health record of…