Reentry Discharge Case Manager

The Reentry Discharge Case Manager will provide a range of client-centered, confidential services that link recently released clients with core care services including medical, dental, mental health, substance use, and supportive care services including legal, medical transportation, emergency financial assistance, food, and housing services. The goal of medical case management is to ensure viral suppression by taking care of any barriers to care services preventing a client from being undetectable.

The Reentry Discharge Manager will provide direct services including navigation, referral, and treatment adherence counseling to ensure readiness for, and adherence to complex HIV/AIDS treatments.

The Reentry Discharge Case Manager will screen and enroll eligible clients in the Women Evolving Program, Corrections Case Management and Medical case management programs, start ADAP and assist with ensuring the client reenters society.

The Reentry Discharge Case Manager will be expected to work from Cook County Jail at least 2 (two) times per week.

The salary range for this role is $49.000 to $53,000.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

• Provide Navigation Services to individuals from Jail and Prison
• Refer clients from Cook County Jail to Corrections Case Management
• Engage in discussion with clients prior to release
• Assist and participate in ongoing discussion and educational sessions on:
• ¾ HIV, Viral Life Cycle and Understanding ART
• ¾ Communicating with Provider, Adherence & Managing Side Effects
• ¾ Review understanding of basic lab tests: CD4 & Viral Load
• ¾ Stigma & Disclosure
• ¾ HIV and Substance Use
• ¾ HIV and Mental Health

Assessments & Service Plans

• Conduct face-to-face assessments and reassessments on an annual basis
• Create care plans that match the identified needs of the client
• Ensure that all clients referred to services are eligible prior to the date of service
• Collaborate with participants and Employment Specialist in developing and taking steps to achieve their personal and professional goals. This includes assistance with addressing such problems as personal and family adjustments, finances, employment, food, clothing, housing, (behavioral) health and physical and mental impairments. This could also include enrolling in benefits, opening bank accounts, obtaining phones and state IDs, finding transportation, and assisting participants in navigating through systems of health care and social service providers.
• Develop and maintain referral relationships for a range of support services
• With an authorized release of information, contact family members or other social supports of participants to discuss their reentry goals and how to support loved one upon release
• In collaboration with Employment Specialist, develop comprehensive services and resources to assist participants with their career and academic planning towards goals

Client Service

• Provide care services linkage and re-engagement support to clients recently released from jail and prison. Recently released is defined as the last 24 months
• Conduct field visits as needed to RW and HOPWA clients who have disengaged from care.
• Conduct outreach services as needed
• Provide Appointment reminders, arrange transportation
• Refer clients to appropriate services highlighted in the care plan
• Refer clients to appropriate social supports to support positive reentry into society
• Screen for income supports for benefits and entitlements to advocate on behalf of client
• Complete emergency financial assistance applications for eligible clients
• Complete payment requests as needed for copays and other out of pocket costs
• Document encounters using designated client database accurately and in a timely manner
• Develop and maintains professional relationships with social service, health, and governmental agencies
• Participate in continuous quality improvement efforts
• Participate in regular supervision meetings, team meetings, in house training sessions (12) and conferences as needed

Partner Relations

• Maintain an awareness of and cultivate relationships with local providers of services including food, housing, mental health and substance abuse treatment, and health
• Be familiar with state and local government agencies and their systems and processes for providing state identification, driver’s licenses, SNAP and Medicaid enrollment, birth certificates, etc.
• Track resource and referral placements in a data collection system
• Comply with all IDOC requirements, policies, rules and regulations during performance of services for the Program and at all times while in IDOC facilities

Other

• Assist with agency-wide activities as directed, including Annual Meeting, AIDS Run & Walk, and others
• Protect organization's value and manage risk by keeping information confidential
• Perform other duties as assigned

The list of essential functions, as outlined herein, is intended to be representative of the tasks performed within this classification. It is not necessarily descriptive of any one position in this class. The omission of an essential function does not preclude management from assignment of duties not listed herein if such functions are a logical assignment to the position.

SUPERVISORY RESPONSIBILITIES

None

EXPERIENCE AND EDUCATION

Minimum Qualifications

• 2 to 3 years of experience with ability to pass background check to gain justice system clearance

Preferred Qualifications

• Associate degree in any human services field with at least 4 years of case management experience OR
• Bachelor’s degree in any non-human services field with at least 2 years of case management experience
• Bilingual (Spanish speaking, reading, writing)
• Reliable transportation

KNOWLEDGE, SKILLS, AND ABILITIES

• Exceptional time management skills
• Strong attention to detail
• Ability to present to large groups, and a comfort level with presentations generally
• Strong customer service orientation
• Ability to work independently and make decisions within span of control
• Dependable and reliable
• Knowledge of HIPAA and ability to comply with HIPAA regulations
• Ability to recognize and solve problems positively and sustainably

REQUIRED CERTIFICATES, LICENSES, REGISTRATIONS

None

WORK ENVIRONMENT AND PHYSICAL DEMANDS

Dependable transportation to conduct field visits. A driver’s license, and car insurance may be required. Physical ability to operate a vehicle may be required. The field environment may contain ADA noncompliant spaces.

The work environment is representative of that found in a general office environment. Tasks involve the ability to exert light physical effort in sedentary to light work, but which may involve some lifting, carrying, pushing and/or pulling of objects and materials of moderate weight (up to 10 pounds.) Tasks may involve extended periods of time at a keyboard or workstation and on the telephone.