Trillium Health, a Federally Qualified Health Center Look-Alike, is a community health center offering access to affordable care for all, with a special focus on meeting the needs of LGBTQ people, communities of color, and underserved populations.

Nationally recognized for outstanding patient-centered care, the team at Trillium Health provides a wealth of knowledge and experience. Our expansive array of services, including testing and treatment, laboratory services, primary and specialty care, and an on-site pharmacy, makes it easier for patients and clients to receive the complete care they need, all in one place.

Our authentic commitment to diversity and inclusion is evidenced through our hiring practices, our employee programs, and our compassion for everyone we serve. Based in downtown Rochester, with satellite locations in Bath and Geneva, and MOCHA centers in Buffalo and Rochester, Trillium is deeply invested in building community. We proudly sponsor many other nonprofit organizations throughout the area and participate in a wide range of community events.

Trillium’s employee-centered company culture and exceptional benefits have contributed to impressive growth in recent years, raising our staff total to more than 250. We hope you will consider joining us on this upward path and becoming a part of the Trillium Health family.

We are currently recruiting for a Case Manager AIDS Institute Grants.

New Patient Intakes

• Ensure all HIV-positive patients new to Trillium Health have an intake in which personal patient information, barriers to care and urgent needs are assessed. Intakes encompass patients who test positive at Trillium Health, community referrals, or patient transfers.
• Provides new patients/clients site tour, overview of available resources, and introductions to treatment team, wrap around teams, etc. if applicable
• Collaborates with local agencies, medical providers, and government programs in order to assist newly diagnosed individuals to link to HIV specialty care at Trillium Health.
• Meets with new/returning patients/clients to complete required intake paperwork, authorizations, and consents based upon desired services, as well as requests medical records from previous providers in order to facilitate transfer of care.
• Function as an insurance assister if needed and obtains required documentation from patients/clients and pursues applications for medication assistance or ADAP.
• Monitors new and returning HIV positive patients following their initial connection with Trillium Health and works to maintain their ongoing and timely engagement in care.
• Promote patient/client access into internal agency services including, but not limited to: support groups, housing services, food programs, behavioral wellness, substance use treatment, and medical care
• Conducts engagement services (including home visits, reminder phone calls, transportation, etc.) to increase the likelihood that new/returning patients/clients will attend first appointments with required staff at Trillium Health (including medical provider, case manager, day health, behavioral wellness counselor, etc.), and will follow up with new/returning patients regarding missed appointments

Case Management/Linkage to Care

• Responsible and accountable for coordinating all aspects of the patient/client’s care.
• Provide comprehensive case management for HIV+ patients/clients with the specific goals of achieving and maintaining viral load suppression.
• Create and execute an individualized patient/client centered service plan that includes community-based and other social supports services in addition to healthcare services that clearly identifies goals and timeframes for improving the patient’s/client’s health and health care status.
• Schedules patient/client for appointments with required staff at Trillium Health (including medical provider, day health, behavioral wellness counselor, etc.), and identifies available community-based resources and actively manage appropriate referrals, access, engagement, follow-up and coordination of services.
• Conduct home visits and hospital visits to meet with patients/clients
• Conducts assessments, re-assessments and service plan development with the client/patient and multidisciplinary team to reduce barriers to retention and adherence.
• Ensure follow-up of tests, treatments, services and referrals incorporated into the patient’s/client’s service plan.
• Ensure that patient/client progress notes are completed and submitted to supervisor within the designated time frame.

Retention and Adherence

• Responsible for contacting and tracking patients who are not virally suppressed and lost to care (no contact for more than 90 days).
• Coordinate case conferences:

o   Schedule and/or participate in case conferences.

o   Facilitate a case conference with providers upon enrollment and every 90 days thereafter.

o   Ensures all patients/clients who are lost to follow-up (no contact for more than 90 days) have a case conference scheduled with the treatment team.

o   Based on case conferences, links patients/clients to services such as the Treatment Adherence Program, Behavioral Wellness, Care Management, partner notification, health education, housing, transportation assistance, etc... 

o   Coordinate transportation for patients/clients, escort them to and from appointments, and conduct home visits as needed.

Miscellaneous

• Requires the ability and commitment to respect and support inclusiveness and diversity, including but not limited to individuals of different backgrounds, cultures, races, ages, sexual orientations, gender identities or expressions, transgender, experiences, opinions, etc.
• Requires individual demonstration of commitment to the One Trillium behaviors and business impacts and modeling them in the organization.
• Responsible for maintaining confidentiality of all patient, client, employee, protected and proprietary information.
• Employees are accountable for meeting the performance standards of their departments and must participate as requested in compliance audits, process improvement and quality improvement plans.
• Other specific duties as assigned.

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Qualifications

Bachelor’s degree in Health and Human Services, Social Work, or a closely related field with 2 years of experience working in the field of HIV/AIDS, behavioral health, substance abuse or other chronic illnesses. Possess an understanding of community level work and the importance of collaborating and coordinating with community based organizations.  Computer proficiency is required. Fluency in Spanish and/or ASL preferred.  Must be accustomed to diversity. Must have a reliable vehicle, a valid NYS driver’s license, and proof of required automobile insurance.

Trillium Health offers employment to all employees & applicants. No person shall be discriminated against in employment on the basis of race, age, color, marital status, religion, creed, sex, sexual orientation, gender identity or expression, national origin or ancestry, disability, veteran status, status as a domestic violence victim, genetic condition or predisposition, or any other characteristic protected by law.

Apply online at https://www.trilliumhealth.org/en/291/careers