Coordinator, Linkage-to-Care - Department of Internal Medicine

Job Purpose

The Linkage-to-Care Coordinator is responsible for ensuring timely linkage, engagement and retention in care for individuals newly diagnosed with Human Immunodeficiency Virus (HIV) and syndemic-associated conditions, as well as those re-engaging in HIV care. This role serves as a vital connector between testing sites, clinical providers, public health partners, and community-based organizations to close gaps in care and improve health outcomes. This position ensures patient-centered navigation, care coordination and follow-up services while addressing barriers such as insurance, transportation, stigma, and broader social determinants of health.

This role supports syndemic-focused public health and clinical goals by promoting rapid connection to treatment, continuity of care and sustained engagement in prevention and treatment services. This position collaborates with Disease Intervention Specialists, Patient Advocates, and Patient Financial Counselors to ensure the effective coordination and delivery of patient care services. Provide direct supervision and performance management for the Medical Case Manager, Outreach Representative, HIV Prevention Specialist, Patient Advocate, and Peer Navigation Specialist, including hiring, onboarding, coaching, training, performance evaluations, and corrective action as needed. Foster a collaborative, high-performing team environment that supports program goals and quality outcomes. This position reports to the Director, Adult HIV Program.

Essential Functions

Linkage-to-Care and Navigation: Coordinate timely connections to medical care for individuals by scheduling initial appointments, facilitating referrals, and supporting rapid initiation treatment when indicated, including navigating available support and assistance programs.

Patient Engagement and Follow-Up: Conduct outreach and follow-up with clients to support engagement and retention in care, including appointment reminders, re-engagement efforts and coordination of follow-up testing and treatment milestones. Ensure individuals are successfully linked to care and remain engaged in ongoing treatment and disease management based on individual clinical needs and condition.

Collaboration and Supervise: Collaborate with Disease Intervention Specialists, Patient Advocates, and Patient Financial Counselors to ensure effective coordination and delivery of patient care services. Provide direct supervision and performance management for the Medical Case Manager, Outreach Representative, HIV Prevention Specialist, Patient Advocate, and Peer Navigation Specialist, including hiring, onboarding, coaching, training, performance evaluations, and corrective action as needed.

Care Coordination and Referrals: Collaborate with medical providers, case managers, Disease Intervention Specialists, Patient Advocates, and community partners to address medical and non-medical needs, including insurance enrollment, transportation, housing, behavioral health services, and substance use support.

Data Documentation and Reporting: Accurately document linkage activities, outcomes and client interactions in electronic health records, surveillance systems, or program databases, ensuring compliance with grant, clinic, and public health reporting requirements.

Collaboration with Public Health and Clinical Partners: Serve as a community outreach liaison between public health agencies, hospitals, urgent care facilities and community health organizations to ensure seamless transition of services, information, and continuity of care.

Health Education and Client Support: Provide basic health education to clients regarding treatment, prevention, and partner services, using trauma-informed, culturally responsive, and stigma-reducing approaches to support understanding and engagement in care.

Quality Improvement and Program Support: Participate in continuous quality improvement activities to identify gaps in linkage processes, enhance outcomes, and support program goals related to syndemic care. Provide reports to quality team and actively engage in program-wide quality improvement initiatives.

Perform other related duties as assigned.