I. SCOPE OF ROLE:

II. The SRO Intervention Project works with homeless and formerly homeless people with HIV/ AIDS
and seeks to connect them to medical services and stabilized housing; The Care Coordination
Redesign Program (CCR) employs a navigation model and a chronic care model to advocate for,
communicate with, and identify resources for the client as well as encourage and support clients
to gain and maintain independence in their healthcare to ensure improved client health
outcomes and improved quality of life.

III. ESSENTIAL DUTIES & RESPONSIBILITIES:

• Responsible for direct, field-based services to enrolled consumers.
• Responsible for supporting the implementation of a comprehensive Service Plan for each
enrolled consumer.
• Assist consumers with securing services for housing, medical care, nutrition and
transportation. Assist consumers with relevant applications and other paperwork for benefits
and support services. Conduct regular social services and benefits re-assessments and follow
ups.
• Visit enrolled consumers between regular clinic visits to reinforce treatment plans, provide
appointment reminders, provide individual health education curriculum, coordinate
transportation and health care needs and other follow up activities as warranted.
• Accompany consumers to all primary care, specialty care and other health care appointments.
Accompany consumer to other social service appointments as warranted.
• Provide field-based Directly Observed Therapy (DOT) Services to consumers assessed to
require this service. DOT includes observing and recording patient medication intake,
compliance levels and assessing and reporting any side effects.
• Provide critical feedback to the other members of the health care team based on observations
in the field.
• Record all service provision for submission on a daily basis.
• Facilitate groups for CCR consumers.
• Document all services in AWARDS Case Management Software.
• Collect and record Primary Care Status Measures data as assigned.

• Participate in daily planning meetings with SRO Intervention Project Team. Periodic
participation in team meetings, case conferences, division meetings and trainings as required
• Participate in Services for the Underserved Quality Assurance/ Quality Improvement activities
• Reports to the Program Director in the absence of the CCR Supervisor.

REQUIRED EDUCATION AND EXPERIENCE
• Minimum Associates Degree. Experience working with people living with AIDS, homeless
people or substance users encouraged. Effective written and oral communication skills.

PREFERRED QUALIFICATIONS & SKILLS

• Bi-lingual Spanish strongly preferred. Experience working within an outreach model or case
management preferred.

• Basic computer skills (e.g. MS Office suite and Windows)

S:US IS AN EQUAL OPPORTUNITY EMPLOYER 

Join a team of employees who cares about the wellbeing of others. We’re proud to offer a comprehensive benefits package designed to support your wellbeing and development. From health and wellness resources to generous PTO, professional development, and more, explore all that we offer on our Benefits Page and see how S:US invests in you. 

We believe in fostering a culture built on our core values:  respect, integrity, support, maximizing individual potential and continuous quality improvement.  

S:US is an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, or genetic information. S:US is committed to providing access, equal opportunity and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities, including allowance of the use of services animals. To request reasonable accommodation or if you believe such a request was improperly handled or denied, contact the Leave Team at MyMedicalLeave@sus.org.