We are seeking an ACE Program Coordinator who will support the multifaceted clinical and research Ryan White HIV/AIDS program in the John G. Bartlett Specialty Practice. The ACE Program Coordinator will lead peer-based engagement and retention initiatives targeted to youth living with HIV. Will coordinate clinical linkage to care services within the ID division, JHH and JHU inpatient and outpatient departments, the Specialty Division of the Johns Hopkins Outpatient Pharmacy, and any external organizations to support a variety of clinical and research HIV/AIDS programs focused on persons under the age of 30. The ACE Program Coordinator will work in a fast-paced environment requiring exceptional organizational and interpersonal skills. The work may involve travel to Baltimore City community-based organizations and clinics to assist in status-neutral linkage to care services at the John. G. Bartlett Specialty Practice.

Overall duties include program coordination, electronic medical record report monitoring, clinical and operations office oversight; work queues and in-basket messaging in collaboration with clinic-specific leadership (i.e. Nurse Manager, Clinic Manager); meeting preparation and coordination; Accessing Care Early Provider coordination for the John G. Bartlett Specialty Practice: coordination and oversight of ED, inpatient, and community HIV/AIDS linkage to care program. The ACE Program Coordinator will monitor community outreach activities and the ACE Linkage to Care program. Primary responsibilities will include planning, implementing, monitoring, and evaluating community and clinic-based HIV prevention and HIV treatment outreach, linkage, and retention activities for youth.Will provide care coordination and peer navigation services for patients enrolling in the ACE program.

Specific Duties & Responsibilities

30% Program Coordination

• Work with the HIV/AIDS Program Supervisor to plan, implement, and monitor patient wellness initiatives, community outreach events, and events that provide general visibility for the JGBSP.
• Coordinate weekly Peer Navigator meetings to develop and discuss patient engagement, linkage, and retention strategies.
• Review educational materials and activities; identify opportunities to conduct outreach and education activities to communities at an elevated risk for HIV and for people living with HIV.
• Coordinate designated patient walk-in clinic sessions and other unanticipated walk-in patients looking to engage in HIV testing, counseling, and linkage to care services; coordinate and document follow-up plan for review at weekly Peer Navigator meeting.
• Assist with design and implementation of virtual and in-person outreach activities, including patient support groups and clinic initiatives e.g., clothing closet, informative listening sessions, and providing technical assistance for patients using virtual technologies
• Work in collaboration with Peer Navigators in tracking and reporting patient enrollment and patient status in their respective program.
• Work closely with the HIV/AIDS Program Supervisor and JGBSP Peer Navigators in presenting qualitative and quantitative data across projects as needed.
• Work closely with HIV/AIDS staff to maintain and expand activities with community partners, including those listed as collaborating partners on HIV/AIDS-sponsored projects.
• Work closely with the HIV/AIDS Program Supervisor, HIV/AIDS project leads, and patient/peer navigators to develop, implement and monitor: data collection protocols, internal and external for patients linking and re-engaging in HIV care, respectively.
• Work together with the ACE Medical Director and HIV/AIDS Program Supervisor to develop and maintain linkage to care protocols and procedures for patients 30 and younger.
• Work closely with the ACE Medical Director on a quarterly basis to report and present patient data.
• Monitor implementation and revision of the ACE program patient linkage to care protocols for JHH ED, JHH inpatient units, and community outreach events.
• Track ACE Provider's clinic show rates and contact patients who miss appointments to reschedule provider appointments and link to Peer Navigator, case manager, nurse, or research coordinator when appropriate.
• Electronic medical record report monitoring, work queues, and in-basket messaging for all ACE Providers (9 providers at present)
• Answer, triage, route, and document ACE clinic phone calls to include internal and external patient and provider questions and/or requests at John G. Bartlett Specialty Practice.
• Run reports: Hold time, no show for ACE providers
• Coordinate and lead with scheduling ACE patient appointments in collaboration with ACE providers.
• Transition patient's care from ACE providers to a general infectious disease provider to continue care.

70% Direct Patient Support

• Provide in-person, virtual support and follow-up to patients newly diagnosed with HIV and patients re-engaging in HIV Care enrolling into the ACE program.
• Provide advocacy, referral, and linkage to community resources and support networks to address identified needs e.g., domestic violence, mental health, family issues, etc.
• Coordinate educational workshops for patients that promote and address self-advocacy, effective communication skills, and additional identified educational lessons as needed.
• Assist clients in navigating a complex medical system by building trust and a professional working relationship.
• Educate patients on self-advocacy skills and empower them to communicate effectively with their healthcare team.
• Work in collaboration with the ACE Nurse in developing strategies for patients who struggle with adherence and show signs of being at risk of falling out of care.
• Act as a liaison between social workers, clinic staff, and patients as needed.
• Communicate any issues of concern (e.g., drug use, non-adherence) to the patient care team.
• Assess and document the patient’s strengths as well as needs to address individual and community barriers to care and intervene as appropriate.
• Assist with the implementation of in-person and telehealth patient groups in the JGBSP.
• Conduct follow-up virtual and in-person meetings and other contacts with patients to ensure that services were obtained; reschedule appointments as needed.
• Encourage patients to use supportive services and counseling (e.g., substance use counseling, therapy, etc.
• Help coordinate and potentially accompany patients to medical, substance use treatment, and social service appointments.
• Meet with inpatients, ED patients, and patients at the JGBSP and/or Johns Hopkins clinics who are newly diagnosed, providing support and encouragement about living with HIV.
• Work closely with medical providers to develop and provide educational resource materials to patients and their families.
• Provide wellness phone calls and support to persons struggling with adherence and/or psychosocial issues (i.e., sexual orientation, gender identity, unemployment)
• Assist with administration of annual patient satisfaction surveys.
• Plan and conduct client focus groups as needed.
• Maintain client confidentiality.
• Document and provide pertinent information regarding services delivered in the EMR.
• Build rapport with community-based agencies to streamline referral processes for housing, domestic violence support, legal services, etc.
• Attend and participate in regularly scheduled staff meetings and conference calls.
• Work closely with other program navigators to plan and conduct navigation and outreach activities.
• Provide HIV testing and counseling services at JGBSP and JGBSP community events.
• Coordinate transportation for patients to and from medical, social work, and other services related to maintaining patients' access to care and supportive services.
• Help set up pre-paid phones for eligible patients, outside of ACE, without a mobile device to communicate with the care team to maintain adherence to treatment plan.
• Obtain social work-related RW documentation to assess and reassess patients’ eligibility for RW services.
  
• Coordinate appointments for the research team to meet with patients who are eligible for research studies within the clinic.
• Escort patients to and from coloscopy procedures to ensure services are obtained.
• Any other duties at the discretion of the program supervisor.

Additional Knowledge, Skills and Abilities

• Excellent writing and interpersonal communication skills, particularly for communicating with a wide variety of individuals from patients to administrative personnel, experienced clinicians, and physicians.
• Ability to adhere to policy and procedures and maintain clear professional boundaries.
• Attention to detail and ability to chart and enter data accurately.
• Complete and pass JHU competency exams in HIPPA privacy.

Physical Requirements

• There is little likelihood of exposure to communicable diseases, hazardous materials, or pharmacological agents
  

• Ability to see within normal parameters.
  

• Communication skills, using the spoken word.
  

• Finger dexterity to manipulate objects with fingers rather than with whole hand or arm, for example, using a keyboard.
  

• Reaching by extending hand(s) or arm(s) in any direction.
  

• Sitting in a normal seated position for extended periods.
• Ability to hear within normal ranges
• Ability to move about.

• Bachelor's Degree in related field.
• Some related work experience.
• Proficiency with MS Word and MS Excel.
• Additional experience may substitute for required education, to the extent permitted by the JHU equivalency formula.
  

• Five years of progressively responsible related administrative experience.
  
• Experience working with people with unstable housing, substance use issues, dual diagnoses, and HIV/AIDS.
• Knowledge of current HIV treatment guidelines.
• Knowledge of some or all the following: Strengths-Based case management, Motivational Interviewing, and principles of harm reduction.

Classified Title: Sr. Community Outreach Specialist 
Job Posting Title (Working Title): ACE Program Coordinator   
Role/Level/Range: ACRO40/E/02/CD  
Starting Salary Range: $17.20 - $30.30 HRLY ($48,000 targeted; Commensurate with experience) 
Employee group: Full Time 
Schedule: Monday-Friday; 8:3am-5:00pm 
Exempt Status: Non-Exempt 
Location: Hybrid/School of Medicine Campus 
Department name: ​​​​​​​SOM DOM ID Bartlett Clinic  
Personnel area: School of Medicine