HIV Registered Nurse (RN)

Position Summary

Under the supervision of the Director of Nursing, the HIV Nurse Case Manager provides client-centered clinical case management services to adolescent and adult clients living with HIV/AIDS. The HIV Nurse Case Manager works collaboratively with patients, families, providers, and community partners to ensure timely and coordinated access to primary care, medications, treatment adherence support, specialty care, and other medical and social services.

The HIV Nurse Case Manager conducts comprehensive clinical assessments, develops and monitors individualized service plans, provides patient education, coordinates referrals, and develops nursing care plans consistent with the client's overall treatment plan. The position also assists patients and families in identifying and accessing needed resources in collaboration with the HIV Social Services Case Manager.

Essential Functions

• Provides Clinical Case Management Services
• Conduct comprehensive initial clinical assessments in partnership with the HIV care team.
• Collaborate with the treating provider and patient to formulate an individualized plan of care.
• Develop, implement, and monitor an Individualized Service Plan (ISP) collaboratively with each client, including action steps and timelines based on the client's identified needs and goals.
• Complete the ISP within 60 days of the initial intake date.
• Reassess client needs and the ISP at least every six months.
• Monitor clients to assess the effectiveness and progress of the individualized service plan.
• Reassess clinical needs at each medical visit.
• Develop and implement nursing care plans consistent with the client's overall treatment plan.
• Coordinates Access to Care and Community Resources
• Ensure timely and coordinated access to:
• Primary care
• Medications
• Treatment adherence services
• Specialty care
• Social services and other community-based support services
• Coordinate specialty care and social service referrals in the community.
• Maintain and update a comprehensive resource list/manual for client referral purposes.
• Schedule appointments, when appropriate, to minimize loss to follow-up.
• Document completed referrals and follow-up activities.
• Assist patients and families in locating and accessing needed resources in collaboration with the HIV Social Services Case Manager.
• Collaborates with the Clinical Care Team
• Work collaboratively with the clinical team and other providers involved in the client's care to promote optimal outcomes throughout the health care continuum.
• Prepare current clinical activity reports and participate in monthly Health Center Clinical Team meetings.
• Report on patient progress and make recommendations regarding changes to the plan of care when necessary.
• Review and follow up on patient laboratory and test results, scheduled appointments, and other measures of treatment compliance and adherence.
• Provide current summary information to the clinical care team regarding client contacts, progress, and completed action steps for patients in the active caseload.
• Conduct home visits when other attempts to contact the client have been unsuccessful and the client is experiencing difficulty maintaining medical appointments or adhering to prescribed medications.
• Conduct hospital visits, as appropriate.
• Provides Patient and Family Education
• Continuously incorporate patient education into the plan of care.
• Reinforce clients' understanding of their HIV diagnosis and other health conditions.
• Develop educational tools and materials to support patient and family understanding of self-care.
• Educate clients regarding medication adherence, disclosure and partner notification, and harm reduction, including safer sex and safer substance use.
• Promote understanding of the client's long-term treatment plan and support adherence to medical recommendations.
• Participates in Nurse Case Management Activities
• Attend team meetings as needed and as requested by clinical team leaders.
• Organize monthly AIDS Education and Training Center (AETC) trainings and in-service education.
• Participate in all Boston Public Health Commission (BPHC) grantee-related training and technical assistance activities.
• Participate in the preparation of quarterly reports and other required data collection and reporting activities.
• Maintain accurate and timely documentation related to client care and case management activities.
• Documentation and Administrative Responsibilities
• Complete all required paperwork and documentation within established timeframes.
• Maintain accurate records related to clinical case management activities.
• Complete required reports and data collection activities.
• Perform other duties and responsibilities as assigned.
• Professional Development
• Continuously maintain and expand clinical knowledge and skills relevant to HIV nursing and case management.
• Maintain all required professional licenses, certifications, and continuing education requirements.
• Participate in relevant training, professional development, and educational opportunities.

Key Functions

The HIV Nurse Case Manager is responsible for ensuring that clients receive timely, coordinated, and client-centered access to care , with particular emphasis on:

• HIV primary care and treatment
• Medication access and adherence
• Specialty care
• Positive prevention
• Patient education and self-management
• Community and social service resources
• Care coordination across the health care continuum
• Ongoing assessment and monitoring of client needs

Requirements

Qualifications & Skills

• BSN or Bachelor’s degree preferred.
• Graduate of an accredited nursing program with a current Massachusetts RN license.
• Current CPR certification required.
• At least three (3) years of nursing experience preferred, with at least two (2) years of experience in adult and pediatric acute care and/or medical-surgical nursing.
• Five (5) years of clinical experience preferred.
• Previous case management experience preferred.
• HIV/AIDS knowledge or experience preferred.
• Strong scientific knowledge base in health promotion and disease prevention.
• Community outreach experience preferred.
• Excellent interpersonal and communication skills.
• Strong computer skills.
• Self-motivated and able to work independently with minimal supervision.
• Bilingual capability in Spanish and/or Haitian Creole desired.

Physical Requirements

• Must be able to stand or sit for prolonged periods (at least 50% of the time)
• Ability to lift up to 25 pounds and load onto shelves
• Visual acuity sufficient for frequent reading and computer use