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Linkage to Care Specialist - Milwaukee, WI
Job Code:2021-SOC-098
FT/PT Status:Social Services
Location:Milwaukee Clinic (WI)

Explore our careers page to learn more about the benefits we offer!

Check out our Youtube channel to learn more about Vivent Health!

Videos to explore!

1) The Basics - HIV Prevention and Testing -
2) How is HIV Transmitted? -
3) HIV: Fight Back with HIV Treatment -
4) HIV: Let’s Reset What We Know -
5) HIV: The Goal of Undetectable -

Position Purpose

The Linkage to Care Specialist provides intensive care coordination, support and services to HIV-positive individuals who require rigorous assistance to improve their ability to access and remain in care. This individual will coordinate with HIV testing sites as needed to initiate access to care; work with clinical staff to promote adherence to medical, behavioral, oral health and pharmaceutical care; provide treatment education; collaborate with other programs within Vivent Health and with local providers; and offer direct interventions to reduce barriers to care for the benefit of patients. The Linkage to Care Specialist will also educate HIV positive individuals on the importance of HIV medical care and empower them to navigate medical and social systems on their own. This position is funded through Ryan White Part B and the Mike Johnson Life Care Services Grant through the State of Wisconsin.

Scope of Responsibilities

Vivent Health is one of the nation’s largest providers of HIV prevention, care and treatment services with a budget approaching $150 million and employing over 450 professionals.

The unique, nationally recognized Vivent Health HIV Medical home model of care assures that everyone with HIV has access to medical, dental, mental health and social services and provides the best opportunity for patients to achieve high quality health outcomes. Vivent Health also provides aggressive HIV prevention services to gay men, injection drug users and others at the highest risk for HIV infection.

Vivent Health currently operates in multiple states nationwide. It embraces a Market Culture to increase access to care, enhance quality outcomes, achieve and surpass financial performance expectations and has an aggressive plan to expand into additional states.

Essential Functions

  • Provide highly focused, intensive, time-limited support to persons newly diagnosed with HIV disease, persons from corrections facilities who are returning to the community (if applicable), persons at high risk for falling out of care, or who have lapsed from care.
    • Conduct immediate response for newly diagnosed clients in clinic or outside testing partner agencies as assigned.
    • Complete intake and other screenings to identify barriers to care and, with the patient, devise possible solutions that are effective and sustainable.
    • Provide case management services, according to the Wisconsin AIDS/HIV Program HIV Medical Case Management Standards, to persons with HIV infection through:
      • Assessments/Reassessments;
      • Service Planning;
      • Coordination of Services and/or Service Plan monitoring;
    • Work with appropriate community physicians, nurse practitioners, therapists, dentists, pharmacists, and case managers to identify patient health needs and to ensure accessible, confidential and high quality services to patients.
    • Work with patient and providers to develop and implement a health care plan to meet patient needs and retain patient in care. This plan will include objectives that will facilitate the client in becoming a good self- health advocate and developing skills needed to navigate necessary health and social delivery systems.
    • Assess benefits and insurance, and if needed, provide assistance to access payor programs. Enroll in Vivent Health’s Medical Home if applicable.
    • Facilitate communication among the care team.
    • Provide HIV disease prevention and treatment adherence education.
    • Assist with making appropriate referrals for services needed to stabilize patient in care and follow-up to ensure service delivery.
    • Accompany patients to health appointments; in consultation with the supervisor, this may include transportation to and from and attendance at the appointment.
    • Provide a level of service that is highly intensive. This involves large amounts of time in the community, at patient homes and in other locations that meet the patient’s needs best. This intensive service is to aid the client in becoming more ready for Community or Clinic case management services and to increase their health literacy and self-management skills.
  • Contribute as an active member of the Social Services Department by participating in staff meetings, in-service trainings and workshops, department or agency planning activities, assisting with special projects, and providing support, peer mentoring and training to co-workers as needed. Provide feedback about best practice standards, program improvement, and unmet patient needs.
  • Collaborate extensively with Vivent Health’s Medical, Dental, Pharmacy, and Behavioral Health Clinics personnel to ensure that clients obtain appropriate and timely access to all needed care, and to maximize adherence to medical treatment plans.
  • Through outreach, education, and collaboration, establish a working relationship with appropriate community resources in the area, including those providing HIV testing and/or health, mental health and social services to underserved and target populations.
  • Maintain appropriate patient files and timely documentation of services utilizing electronic case management and/or medical software such as Provide Enterprise and EPIC.
  • Update and maintain a strong working knowledge of HIV/AIDS, treatment options, risk reduction techniques, chronic diseases, mental health issues, case management, and other related issues through self-study and participation in trainings, workshops, and in-services and in consultation with supervisor.
  • All other duties as assigned.

Required Experience and Skills

  • Ability to establish and maintain effective public and working relationships with culturally diverse populations from a wide range of life circumstances and backgrounds.
  • Demonstrated effective written and verbal communication skills, including client-centered communication and assessment skills.
  • Ability to effectively organize work products and files, keep clear records, and manage time well so as to optimize efficiency and productivity

Additional Preferred Experience

  • Extensive knowledge of medical, social and mental health delivery systems.
  • One year or greater field experience in outreach-type activities, conducting screening, providing education and/or direct services in a community-based health clinic or social service environment.
  • Extensive knowledge of HIV disease and related issues, disease progression, and treatment options.
  • Working knowledge of Spanish language (bilingual) is a plus.


*Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions*

**Equal Employment Opportunity/Affirmative Action Employer* *

Vivent Health is an equal opportunity employer and will recruit, hire, promote and transfer qualified persons into all job classifications regardless of race, gender, religion, skin color, national origin or ancestry, physical disability (including pregnancy) or mental disability, age, gender identity, sexual orientation, legally protected medical condition, family care status, marital status, veteran status, genetic characteristics or any other characteristic protected by federal or state law. Vivent Health complies with other expanded protected classifications that may be mandated by specific county or municipal regulations. As a recipient of federal funding, Vivent Health will not hire nor enter into a contractual relationship with any party that is debarred, suspended, or excluded from federal assistance programs.

*Public Student Loan Forgiveness*

Employment at our organization may qualify you for federal student loan forgiveness programs. We do not directly pay for – nor forgive – federal student loans; however our status as a not-for-profit organization under Section 501 (c) (3), makes us an eligible employer. There may be other determining factors for one to qualify.

Please follow this URL to review one such program and their requirements: