Description

POSITION SUMMARY

In 1967 West Oakland Health (WOH) was organized as an alternative healthcare facility. While its creation was not a radically new idea, it was a radical act. The idea of West Oakland Health was crafted by a group of West Oakland residents who decided that the West Oakland Health Center should reflect a tradition of Black institution building as a form of recourse to health inequality. And that should be guided by three principles: 1) provide trustworthy options for Black and low-income communities; 2) provide and model respectful and reliable medical practice that validates the experiences and needs of the community; and 3) serve as a hub for the Black community's attention to community health.

Consistent with this tradition is WOH's dedication to eliminating the prevalence of HIV infection through routine screening, education, and linking patients to care through evidence-based practices. The HIV Care Coordination Health Advocate will work closely with the Clinic care teams to ensure gaps in care are closed and people receive appropriate care for their medical conditions. Under the general supervision of the Director of Research, Evaluation, and Community Health, the HIV Care Coordination Health Advocate will assist patients and care teams in achieving timely access to needed care, comprehension and continuity of care, specialized case management services provided to highly complex patients, and enhancing patient well-being.

Care coordination aims to improve people's care at West Oakland Health (WOH). Care coordination is an organized, population-based, multidisciplinary team approach in which a primary care team jointly plans and manages the care of patients. The critical element of population health management is using a population health registry and electronic health record (EHR) system to ensure that the entire patient population receives support for disease care and symptom management. The reports generated from the EHR or any other population health registry system are repeatedly reviewed to ensure that all tasks related to providing preventive and chronic care (subject to patient preference) are performed. Other elements of care coordination may include health coaching, physician-created standing orders for common problems, and active outreach.

DUTIES

1. Assist with the development and implementation of strategies to reach target populations.
2. Help patients access ongoing medical care through navigation and follow-up, including but not limited to tracking referrals, identifying gaps in care, maintaining patient registries, proactive outreach to disengaged patients, post-emergency department and post-hospitalization care coordination, and linkage to case management services.
3. Ability to collaborate with housing, education, and other social service partners to educate and engage patients in their medical care.
4. Provide an effective communication link between patients and medical staff, including relaying messages from providers, gathering information from patients for providers, etc.
5. Effectively communicate using all available tools to engage patients with care.
6. Attend training, and care coordination meetings as required.
7. Provide support for internal and external referrals by following up with patients, requesting specialist visit reports, and closing the loop.
8. Participate in community outreach events to promote the services of WOH and health promotion activities.
9. Ensure all patients are tracked, and data is entered into Epic EMR and any other population health registry system if necessary for follow-up and tracking purposes.
10. Participate in team decisions regarding data requirements for proactively coordinating the team's panel.
11. Assist in coordinating care with pharmacies, insurance companies, and other providers in the community. Ensure that information goes when and where it is needed.
12. Completing a health and social determinants assessment.
13. Other duties as assigned.

Qualifications

QUALIFICATIONS

1. Bachelor's degree or equivalent experience in Health Education, Social Welfare, Psychology, Public Health, Health Communications, or Nursing; OR certification/experience working as a Medical Assistant, Community Health Worker, Certified Application Assister or Eligibility Worker, etc., in a health care setting.
2. Minimum of two years of experience providing HIV services related to this position, including experience working within underserved communities.
3. Prior work-related experience with HIV populations, active substance users, homeless individuals, transgender people, men who have sex with men (MSM), and other vulnerable groups.
4. Access to reliable transportation. Willingness and ability to travel across Alameda County to perform work.
5. Ability to project a positive image to the public.
6. Proficient in Microsoft Office Suite with knowledge of Electronic Health Records preferred.
7. Ability to remain calm and courteous in a high-stress environment.
8. Ability to work independently with a minimum of direction.
9. Excellent communication skills.
10. Excellent interpersonal and time management skills, ability to work effectively in a fast-paced environment with rapidly shifting priorities and competing demands.
11. Excellent organizational and time-management skills.

GENERAL REQUIREMENTS

1. Attends work regularly and punctually; is readily accessible during work hours to peers; limits absences from own duty stations and limits visits and activities which distract others from their performance of duties.
2. Works cooperatively with immediate supervisor, department members, and other WOH staff persons, as required.
3. Treats all patients /visitors with respect and courtesy.
   • Confidentiality of patient/client / fellow employee and supplier records
   • Patient's rights and responsibilities.
   • Professional and business ethics.
   • Continuous quality and improvement.
   • Safety and security of person and property.
   • Infection control.
   • Hazardous materials and waste.
4. Maintaining a working knowledge about and continued compliance with all those areas listed under item (3) throughout your employment with WOH.