Job Description

Outreach Medical Case Manager

The Outreach Medical Case Manager is dedicated to the identification of newly diagnosed People Living with HIV/AIDS (PLWHA), previously diagnosed PLWHA, and PLWHA who are returning to care after more than a 12 month absence and their continuous engagement with HIV/AIDS treatment, programs, services and support systems.  The Outreach Medical Case Manager (OMCM) also will be responsible for working with the Data Base Coordinator to identify former clients who have fallen out of care in order to re-engage them in their care and treatment.

The OMCM performs HIV medical case management functions, working with patients to help them become stable, independent and manage their health.  These functions will include keeping patients engaged in treatment; medication compliance; referral services; follow ups; mental health and substance abuse assessments, etc.

Essential Duties and Responsibilities

  • Utilize the Electronic Health Records and CAREWare database systems to review those who have been out of care for more than 12 months and those who were diagnosed and never returned for care.
  • Provide outreach via telephone, letter, home visits or other creative ways with the goal of getting the client back into treatment and develop a plan to retain them in treatment.
  • Clients who return to treatment will be followed closely by the OMCM.
  • OMCM may make appointment reminder calls to clients for reinforcement and support
  • The OMCM will call clients who do not keep their appointments in order to make certain that they reschedule.
  • OMCM will work with other CS-HHC staff and ID Division staff to schedule appointments in the EHR system.
  • The OMCM will meet with all new patients and established patients in clinic rotation.
  • Work as part of team to deliver results to newly HIV positive diagnosed clients to facilitate relationship building and client engagement.
  • Responsible for specified days on the MCM clinic rotation schedule.
  • Assess clients in a timely fashion so that their needs can be identified.
  • Identifies outreach locations for target population recruitment and provides HIV/AIDS and viral Hepatitis outreach and education and testing as well as tuberculosis and STI education.
  • HIV and HCV testing in accordance with regulatory standards of care.
  • Works closely with ID Specialist and in-house Medical Case Managers as well as the Homeless Department and Hospital discharge patients to identify and locate patients who are lost to care and/or having difficulty maintaining their treatment plans to re-engage back into treatment or assist with adherence.
  • Coordinates referrals and follow-up with other case managers in a timely and professional manner
  • Promotes coordination of service delivery and prevents duplication of services
  • Follows up on results of services provided to clients in a timely fashion
  • Consistently provides great customer service for clients
  • Maintains client confidentiality and ensures compliance with agency, state, federal and HIPAA laws
  • Works with clients to participate in focus groups, consumer advisory board, patient satisfaction surveys and other activities to improve services.
  • Attends and participates in team meetings
  • Performs all other duties as assigned by the Program Director


Education: High school diploma/GED required. Bachelor’s Degree, and/or CADAC preferred.

Experience: Minimum of two (2) years case management or Human Services and great customer service experience is preferred.  Case management experience in HIV/AIDS services is preferred.  Excellent working knowledge of New Haven community and social and health service agencies is preferred.

Knowledge/Abilities: Must have some knowledge of/competency in HIV/AIDS service delivery. Must demonstrate age specific/population specific competencies.  Must demonstrate cultural competence.  Knowledge of/competence with HIV/AIDS and Viral Hepatitis, HIV and HCV disease progression and medication adherence issues.  Excellent interpersonal verbal and written communication skills and the ability to work cooperatively and collaboratively with interdisciplinary health professionals, other service providers and a diverse and multi-cultural client/patient population are required.  Must be willing to do outreach in economically disadvantaged neighborhoods at non-traditional work hours.  Familiarity with substance abuse treatment options. Ability to relate well to target consumer populations, particularly the LGBTQ population as well as professional personnel.

Excellent organizational skills required to maintain job functions. Ability to generate high level of client satisfaction. Knowledge and skills related to individual, group, and family system dynamics. Knowledge of and demonstration of professional ethics. Bilingual (English/Spanish) ability is preferred.


How to Apply

Cornell Scott - Hill Health Center Hartford