Clinic Case Manager

Website Vivent Health

Job Code: 2022-SOC-040
FT/PT Status: Social Services
Location: Green Bay (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 Clinic Case Manager provides a wide range of intensive, client-centered services to persons with HIV/AIDS within a clinic setting to ensure access to and retention in health care, and to address medical, psychosocial, and/or other issues that present obstacles or barriers to care. The Clinic Case Manager is part of a care team that includes physicians, nurses, nurse practitioners, behavioral health therapists, dental care providers, and other care providers. The Clinic Case Manager is an integral part of Vivent Health’s Medical Home, working as Care Coordinator and Team Leader for enrolled patients.

Scope of Responsibilities

Vivent Health is one of the nation’s largest providers of HIV prevention, care and treatment services with a budget approaching $225 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

  • Within an HIV Medical Home environment, work with a team of physicians, nurses, and other practitioners to optimize access to care by persons with HIV infection and to provide necessary education, support, referral, and guidance so that patients can more readily improve their health status.
  • Provide HIV medical case management services, in compliance with State and agency standards, to persons with HIV infection within the clinical setting. This includes:
  • Comprehensive assessment to determine health and psychosocial needs;
  • Assessment of benefits, insurance, and other payer status and provision of assistance to access benefits programs;
  • Development of an individualized service/care plan to improve patient’s health status and plan monitoring to assess progress towards goals;
  • Coordination of and referral to needed medical treatments or specialty care and follow-up to these;
  • Provision of assistance, advice, and/or referral (when appropriate) to Community Case Managers or Housing staff to address housing needs;
  • Provision of treatment adherence counseling;
  • Provision of interventions needed to retain the patient in care;
  • Provision of HIV, chronic disease and general health education to expand the patient’s health literacy and improve general health;
  • Maintaining compliance with case management standards for clients/patients assigned, including performing reviews and reassessments as required, updating service plans, and maintaining contact as required by client’s acuity level.
  • Meet with patients/clients immediately before or after their medical appointments to address any identified needs; all patients are eligible for this brief review, regardless of their eligibility for formal case management services.
  • Collaborate extensively with Medical Home team and clinic personnel to identify and address issues, to ensure that patients obtain appropriate and timely access to care, and to maximize adherence to and retention in care. Coordinate communication with clinical staff, clinical support staff, and external disease management as appropriate.
  • Educate, assess, and enroll eligible patients in Medical Home; coordinate care for enrolled patients on the provider team, to ensure that monthly touches, team staffings, care plan development and monitoring, SBIRT activities, and annual assessments are accomplished and that patients are retained in care.
  • Through training, become “specialized” in a particular area of interest(s) connected to department and client/patient need, thereby becoming an expert and lead in said specialization(s). Such specializations include 340b, SBIRT, and New Patient Orientation, among others.
  • Maintain appropriate client/patient files and timely documentation of services utilizing electronic case management and/or medical software such as SCOUT or Provide Enterprise, and EPIC.
  • Contribute as an active member of the Social Services Department and Health Services care team by participating in staff meetings, patient/client staffing, Health Services planning activities, Medical Home meetings, SBIRT supervision, 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.
  • Establish and maintain effective working relationships with appropriate community resources, especially those providing HIV testing and health, behavioral health and social services to underserved and target populations. Interface with community Case Managers of medical patients who receive case management services at other CBOs, in order to provide updated information as needed for optimum client care.
  • Inform clients/patients of the services available through Vivent Health and in the community and link clients/patients to them as appropriate. At times this may include providing or assisting with the provision of support services such as support groups, food pantry, housing assistance, holiday gifts and school supplies for kids, volunteer services, transportation assistance, and financial assistance.
  • 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.
  • Any 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.
  • Knowledge of and sensitivity to the HIV/AIDS patient population, and/or an eagerness to learn about this community.
  • Adheres to all agency policies including, but not limited to, Employee Handbook, Confidentiality, Healthcare Corporate Compliance Plan, Standards of Conduct, and other policies.
  •  An Influenza vaccine is required of all new employees at the time of employment, and is required thereafter on an annual basis.
  • A tuberculin/TB skin test is required of all new employees at the time of employment, and may be required thereafter on an annual basis, depending on position.

Additional Preferred Experience 

  • Minimum of two years’ experience offering direct client contact in a community based social service or health service agency.

Additional Preferred Qualifications

  • Extensive knowledge of HIV disease and related issues, disease progression, and treatment options.
  • Extensive knowledge of medical, social and mental health delivery systems.
  • 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:

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