Provide comprehensive health assessment of client as baseline data, and develop comprehensive written service plans for each client outlining service needs in accordance with the Ryan White Care Act, Dept. of Health and HIHAF policies, procedures and guidance.

Assessment of nutritional status, including weight stability

Assessment of current medical treatment plan and current medication list

Nutritional counseling specific for HIV infection and/or disease.

Assessment of home health environment, determining any need for home health assistance.

Develop with client a mutually agreed upon “Service Plan”.

Implementation and facilitation of the “Service Plan” covering all aspects of care.

Up-date and re-evaluation to the ”Service Plan” whenever a change in client condition warrants and/or every six months .

Keep updated on latest HIV medications and treatments through webinars, HIV treatment updates or HDAP formulary updates.

Facilitate linkages between clients and appropriate medical community resources.

Provide appropriate referrals to health community resources.

Provide regular and ongoing monitoring of clients around health issues and services provided.

Provide regular and ongoing monitoring of service providers and services provided to clients.

Coordinate with other Medical Case Managers, Housing Coordinator, Health Insurance Kokua, Syringe Exchange and Community Outreach Workers to support the entire individual in maintaining their maximum health outcomes.

Facilitate discharge planning meeting from hospital and other institutions, as appropriate.

Identify gaps in community resources and services, and facilitate resource development and capacity building within the human service community in coordination with Director of Programming and Executive Director.

Provide liaison services between clients and doctors, institutions and community as required by the individual medical provider.

Maintain confidential written and electronic records for each client, and document all service deliveries into the E2 Client Database using SOAP notes.

Update Acuity report monthly.

Prepare and submit Ryan White Client Payment Requests.

Coordinate with H-Programs to certify for H-Programs and do re-certifications every 6 months.

Represent KH+W at community meetings with the authorization of the Executive Director.

Perform outreach and education on HIV issues in the community.

Help facilitate trainings and programs for clients, doctors, and other interested parties in the community.

Work closely with Community Outreach Workers to provide the most accurate and up to date medical information regarding HIV and other STDs to the clients and community.

Attend in person or by telephone all joint staff meetings.

Participate in training and activities necessary to keep abreast of the latest information, treatments and benefits (federal, state and county).

Carry out and complete all other related duties as assigned by the Director of Programming or Executive Director. Adjust work schedule when necessary to meet program needs.

Abide by all policies set forth in the employee manual.

Participate in the fundraising activities of the Foundation.

Abilities and Experience:

Ability to speak to and work with a variety of people from various ethnic and socioeconomic groups around issues of sexuality and HIV.

Ability to translate complex information about controversial sexual and medical issues to individuals and groups with varied educational levels and backgrounds.

Ability to work with other people in a collaborative manner.

Ability to communicate both verbally and in writing.

Broad based knowledge of HIV infection and AIDS.

Broad based knowledge of STD’s.

Have strong written and verbal communications skills for specific prevention/education outreach programs.

Ability to use office equipment, including computers and software packages proficiently.

Have transportation, i.e., automobile, etc. which is fully insured and has current registration, safety check, and Hawaii driver’s license.