The Intensive Care Coordinator works with persons living with HIV who are poly-diagnosed and battling with active mental health or substance abuse issues, along with addressing HIV-related needs. The Intensive Care Coordinator works with patients to facilitate optimal patient outcomes (viral load suppression); promote ongoing long term engagement in medical care, and ensure appropriate service utilization eliminating any gaps in care. The Intensive Care Coordinator assists clients in removing barriers to staying in care through facilitating access to support services and benefits. Specifically, they focus on aiding clients who are apprehensive in addressing their symptoms or addiction, unable to maintain their medical appointments, not medication adherent, or not attaining viral load suppression. The Intensive Care Coordinator works closely with the patient’s medical providers to understand what their medical needs are in addition to their psychosocial needs. The Intensive Care Coordinator is responsible for patient assessment, service plan development, periodic reassessment of needs, medication adherence counseling, patient education, ongoing monitoring of medical and psychosocial needs, monitoring and evaluation of the patient’s progress, and patient discharge from services.



  • MSW or Master’s Degree in related health/human services field preferred. Bachelor’s Degree in related health/human service field required or related direct client service experience which has been performed under the supervision of a human services professional for a period of two years of full time service.
  • Must successfully complete Case Management Training within the first year of employment. Prior substance abuse experience (minimally certified alcohol and drug counselor or certified prevention specialist) desired.2
  • Comfortable in a culturally diverse environment and demonstrate awareness of the value of cultural competence, sensitivity in task implementation, and comfort engaging in conversations regarding sexual health and well-being.
  • Ability to take initiative/ownership and showcase interpersonal skillset. Good verbal and written skills. Able to communicate effectively.
  • Understanding of the functions of patient advocacy and knowledge of rules and regulations concerning HIPAA and client confidentiality.
  • Well-organized and demonstrated ability to prioritize multiple-tasks; self-driven;achieve desired results and adapt favorably to changing priorities. Highly effective problem solving ability. Analytical ability sufficient to resolve problems requiring the integration of data from diverse sources.
  • Computer literate, proficient in Microsoft Outlook, able to learn and effectively utilize client software data base.



  • Demonstrates competency in all facets of clinical interaction including intake, biopsychosocial assessment and reassessment, service planning, progress notes, resource knowledge, referrals, ability to develop rapport with patients, provide health education related to risk reduction and medication adherence. Familiarity with how public and private insurances work and with the website. Possess a working knowledge of regulations relating to Medicaid & Ryan White Care Act; familiarity with and ability to navigate the ACA enrollment process and website; familiarity with how private and public insurances work.
  • Demonstrates mental health competency in the ability to provide in-home/in[1]community mental health assessments, diagnoses, and administer appropriate mental health tools, and to develop appropriate treatment plans with client and complete documentation in order to show progress or reasons regarding lack thereof and revise treatment plan with client as necessary.
  • Work with individual clients to maximize their health outcome with the optimal goal of viral load suppression and help patients achieve this through referral, linkage, coordination, and monitoring of supportive and medical services including providing medication adherence counseling. This may require daily contact regarding medication adherence, and possibly weekly meetings to monitor progress and stabilization.
  • Implements and evaluates plan of care for each patient. Conducts ongoing review of client’s needs and actively links them to appropriate resources. Coordinates with the patient’s medical providers to monitor their progress, identifies any needs related to their medical services, assists in facilitating clients linkage and follow through on service/resource obtainment.
  • Works as part of interdisciplinary team to achieve optimal health outcomes for patients, such as viral load suppression. Coordinates services and referrals with other members of the team to prevent any gaps in services. Focuses efforts on supporting medical plan of care and keeping patient retained in care. Participates in interdisciplinary team cohorts by providing review of client’s needs, services, linkage, and progress with goals.
  • All clinical documentation (intake, assessment, reassessment, service plans, progress notes, releases of information, etc.) are completed fully and within time frames designated. All administration documentation (URS, service activity logs, quarterly grant data statistics submission) are completed fully and within time frames designated.
  • Educates and builds relationships with other providers of service including physicians, clinics and the public. Maintains awareness of community changes which could impact service delivery. Conducts community outreach and networks with other service providers developing new venues for the program to participate in.
  • Maintains professional conduct with colleagues and facilitates effective interaction in one on one situations and in meetings. Ability to be a team player. Participates in ongoing trainings to increase skill level as both a presenter and an active audience member. Maintains knowledge of current requirements of regulatory, licensing and accreditation agencies including Standards of Care for HIV/AIDS case management and Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents.
  • Staff maintains professional conduct with clients including being on time for visits, returning phone calls, maintaining professional boundaries and educating clients on all MHS services. Understanding of the functions of patient advocacy and knowledge of rules and regulations concerning HIPAA and client confidentiality. Comfortable in a culturally diverse environment and demonstrate awareness of the value of cultural competence, sensitivity in task implementation, and comfort engaging in conversations regarding sexual health and well-being.
  • Performs other duties as assigned.



Works in multiple different sites including office, medical clinics and community settings including doing patient home visits. Periodically may need to see patient who are hospitalized. It is common to drive to multiple locations, sometimes in inclement weather. Primarily works traditional business hours but at times may need to be able work non-business hours, such as on weekends or evenings.



All personnel of Matrix must adhere to the NASW Code of Ethics and incorporate Continuous Quality Improvement efforts into their everyday performance. All employees of Matrix Community Health must adhere to the federal regulations and requirements of the respective grant funding their position as well as the Performance Standards, Licensing rules, and be of Good Moral Character as stated in the Code of Ethics.Demonstrate and actively promote an understanding and commitment to the mission and values of Matrix Human Services.

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