Lead Community Health Outreach Specialist

Amida Care, the largest Medicaid HIV Special Needs Plan in NY, delivers a uniquely effective care model that has become a true benchmark for innovation, engagement and member health outcomes. Our mission is to provide access to comprehensive care and coordinated services that facilitate positive health outcomes and general well-being for our members. This true integrative care model addresses psychosocial, housing, behavioral and medical services directly evolving around the needs of each member.

We are a community of individuals from diverse peoples who work together to actively foster a fair, equitable, inclusive environment where all employees receive an invitation to belong. Visit http://www.amidacareny.org for more information about the Amida Care culture.

We are actively seeking a highly motivated, innovative and experienced leader to join our team as the Lead Community Health Outreach Specialist. Compensation will be commensurate with experience.

Position Summary:

This position will assist the Supervisor of Outreach Programs in the oversight of Community Outreach Specialist; ensuring quality control over work: assist with caseload assignments, ensure staff adherence to policies and procedures. This position will also have a partial case load to locate and engage members who are lost to care, at risk of becoming lost to care, providing health promotion and education to individuals who need additional support with adhering to their prescribed regimen. Through member assessment, the Lead community Outreach Specialist will develop goals with members, supports members and service providers, and provide health education to support members to achieve optimal health outcomes. This position will develop and maintain external and internal relationships with service providers to ensure proper engagement and the delivery of appropriate services.

Responsibilities:

• Work with the Supervisor of Outreach Programs to assign cases to staff as referrals are made to RICU by sources such as PCPs, ICTs, Quality Care Initiative.
• Review case notes daily in database and ensure that Community Outreach Specialist input case notes within 72 hours.
• Work with Supervisor of Outreach Programs, Community Outreach Specialist on quality assurance issues including closing of the charts, ensure timely follow-up on referrals, and data collection.
• Collaborate with Health Services and the Integrated Care Team (ICT) case conference coordination.
• Perform telephone, internet, and field outreach to members who are at risk to be lost to care, lost to care, or not in effective care, to locate them and engage and provide health promotion and education.
• Conduct needs assessments to determine barriers, what services and level of health education members need.
• Develop individualized goals and treatment plan with members, based on their needs.
• Provide treatment adherence services to Amida Care members; including but not limited to DOT, appointment escorts, treatment adherence education, and treatment adherence tools.
• Monitor progress through escorts, blood work results and case conferencing with PCP.
• Case conferences with Amida Care staff involved with members and provide updates, as well as seeking assistance as needed to complement the care of members.
• Document all outreach efforts within Salesforce - Team Connect, within 48 hours of event.
• Educate members and provide assistance with making appointments with primary care providers and specialists.
• Conduct on-going follow-up with service providers to ensure members are engaged in services and document steps taken towards member goals.
• Proactively run reports and review databases, to identify individuals who would benefit from outreach to assist in increasing Amida Care's overall viral load suppression and engaging members to effective care.
• Escort members to appointments as needed.
• Educate and assist members in setting up transportation when appropriate.
• Attend meetings, training courses, outreach events, and conferences when appropriate.
• Review various databases to assist in finding difficult to reach members.
• Meet routinely with Supervisor of Outreach Programs for guidance and suggestions of cases.
• Refer and connect members to appropriate services/service providers.
• Perform other duties as assigned.

Amida Care is Diversity, Equity and Inclusion employer committed to full inclusion and elimination of discrimination in all its forms. We strive to develop, promote and sustain a culture that values equity and leverages diversity and inclusiveness in all that we do.

EDUCATION REQUIRED

• Bachelor's degree in human services or five (5) years' relevant experience in HIV medical case management/care coordination.

EXPERIENCES AND/OR SKILLS REQUIRED

• Demonstrated intermediate knowledge of Microsoft Office and CRM databases.
• Demonstrated excellent communication skills: oral and written.
• Ability to maintain routine records pertaining to participant utilization of services as well as to prepare summaries.
• Demonstrated knowledge of sociological and behavioral factors influencing behavior and attitudes of priority group members relative to program to which assigned.
• Demonstrated judgment of safety, boundaries and confidentiality issues.
• PHYSICAL DEMANDS: This position is a field-based position, the employee is constantly required to stand; walk; ride the bus/subway to all 5 boroughs of New York City. The employee commutes, approximately 75% of the time, to meetings, training, and home visits as scheduled throughout the year. The employee spends approximately 25% of the time writing and/or keyboarding. The employee works mostly outside and sometimes in a variety of weather conditions.
• Demonstrate understanding and sensitivity to multi-cultural values, beliefs, and attitudes of both internal and external contacts.
• Bilingual in Spanish preferred.