Position Summary This position works with clients to develop a care plan that will lead to stability, self-sufficiency, and create conditions amenable to client self-management of their health. Care coordinators will participate on the team of providers, and may be the lead of that team. The role of the Care Coordinator includes assisting the client in accessing medical programs. This includes CAREAssist, OMIP, Medicaid, Medicare, FHIAP. COBRA/Portability, private insurance, Pharmaceutical Patient Assistance, Debt Forgiveness programs, and other local, state and federal medical assistance programs. Ongoing advocacy and support is provided to the client in order to maintain access to medical assistance programs, and minimize any break in access to medical care. This position will assist clients in accessing private and government social services to meet basic needs such as housing, transportation and food, as well as alcohol and drug programs, mental health services, vocational programs and SSI/SSDI. The Care Coordinator facilitates this access through the provision of referrals, and additional coordination or advocacy as needed. In addition, this position coordinates access to support services provided through the Ryan White Treatment Modernization Act of 2006. Essential Functions and Responsibilities Client Care Client identification, outreach and engagement Psychosocial assessment of need; Provide direct one-on-one and phone care coordination services Visit accompaniment services Make appropriate referrals, including follow up and documentation. Conduct phone and face-to-face assessments and annual reassessments Development of a service plan or care plan Advocate with other case managers and other service providers on behalf of our clients HIV education, including explanation of available services, and partner programs Implementation of the care plan by linking with service delivery systems; Monitoring of service delivery and reassessment of needs Meet with clients in person on a drop-in and scheduled basis Support Maintain up to date referrals for clients in our service area Develop and strengthen relationships with service providers in our service areas Maintain up to date information regarding OR Medical Assistance programs Maintain up-to-date HIV knowledge; Maintain up to date information regarding other benefits and entitlements programs available in Oregon. Maintain up-to-date and accurate client records, including CareWare Participate in required training pertaining to case management Participate in necessary meetings Assist Director with all necessary reports Participate in agency teams Other duties as defined by Director and Ryan White Principles and Standards For a complete job description, please visit: https://hivalliance.criterionhcm.com/jobs/51/1/#536