Community Health Worker/RAP
Company: Anthony L. Jordan Health Corporation
Location: Rochester
Posted on: February 15, 2026
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Job Description:
Job Description Job Description Description: JOB PURPOSE: To
provide linkage and retention of patients in HIV primary care,
identify patients lost to care, and develop a comprehensive
approach to assessing and assisting patients at risk for
non-compliance, non-retention, and non-adherence to HIV care and
treatment. Additionally, this position will focus on expanding the
PrEP Program through providing patient education, engagement,
navigation, retention, and adherence counseling services. MAJOR
RESPONSIBILITIES (Essential functions): Result 1: To identify
patients eligible for services per RAP Program Standards and
document required information in AIRS, Caseload, and the Electronic
Medical Record system: · Conducting oneself in a professional,
courteous, and friendly manner. · Occasionally greeting PPC
patients when they show up in the reception area and inquire about
needs other than clinical expectations. · To verify that
prospective HIV patients are newly diagnosed, not virally
suppressed, residents of New York State, and meet income
guidelines. · Document patient enrollment information in AIRS and
the Electronic Medical Record system (eCW) per RAP Program
Standards. · Collaborate with PPC Providers and nurses to support
the continuum of care to the benefit of patients Result 2: Clinical
Adherence Management and Direct Client Services: · Provide
immediate and short-term support to patients who may experience
mental, physical, emotional, and behavioral distress. · To conduct
adherence assessments for retention and adherence barriers
(housing, social support, and mental health) at the time of
enrollment. · Develop and implement a strength-based,
individualized treatment adherence service plan within 30 days of
the patients’ initial PPC appointment based on the patients’ needs
and goals. · To provide individual treatment adherence counseling
and monitoring of patients enrolled in the RAP Program. · The
Community Health Worker/RAP will case conference with each patient
quarterly, addressing progress in achieving goals, medication, and
viral load status, and discussing strategies to address identified
barriers. · Use evidence-based retention and medication adherence
interventions. Result 3: Care Coordination and Multidisciplinary
Integration: · Utilize a multidisciplinary team approach with the
entire PPC department (physicians, nurses, case managers, and
behavioral health staff) to ensure that patients are adherent. ·
Case conference with each patient quarterly to address progress,
medication status, and strategies to address barriers. · Utilize a
multidisciplinary team approach with the entire PPC department to
ensure patient adherence. · Collaborate with case management,
pharmacy, substance abuse treatment, and mental health services to
improve retention and medical outcomes. · Conduct re-engagement
efforts for patients who have not had blood work in six months or
attended a doctor’s appointment in over a year. Result 4: Program
Administration and Outcomes Monitoring: · Re-evaluate patients’
service plans and assessments every three months and update them as
necessary in AIR and the Electronic Medical Record system. ·
Collaborate with case management, pharmacy, substance abuse
treatment, mental health, and other services to improve retention,
adherence, and medical outcomes for PLWHA. · Facilitate home visits
to the patient’s home to increase treatment adherence goals and
outcomes. · To conduct re-engagement efforts for those patients who
have not had their blood work in at least six months or who have
not attended a doctor’s appointment in more than a year. · Work
with the Program Manager to address Quality Improvement activities.
· Report monthly on the outcomes, performance measures, and quality
improvement activities. · Promote medication adherence through
regular check-ins, skills-building, and client-centered
motivational interviewing techniques. · To document case closure
for those patients who have maintained viral load suppression for
two consecutive viral load tests, at least ninety days apart or
have left the program for another reason (lost to care or transfer
out of the RAP program) · Perform other duties as assigned.
Requirements: EDUCATION AND EXPERIENCE REQUIRED: · B.A. or B.S. in
Psychology, Social work, Counseling, Substance abuse counseling,
Sociology, Community health, or Public Health; or at least two
years of experience in the field of HIV/AIDS. · One year of
experience providing health education or case management, and
familiar with psychiatric disorders, substance abuse, and cognitive
impairments. · Fluent in English and Spanish. · Valid NYS driver’s
license. · Experience in health treatment: treatment plan, program
implementation, and or direct delivery of health services. ·
Ability to deliver health education services and coaching. ·
Effective communication and documentation skills. · This position
requires some expertise in Medicaid, Medicare, and ADAP insurance
programs. · Sensitive to confidential information and HIPAA
regulations. SKILLS AND KNOWLEDGE REQUIRED: · Strong writing and
computer skills · Possess and utilize effective verbal and written
communication · Ability to be self-motivated, work independently,
and work as a team member · Ability to represent the agency in a
professional manner within the community · Skills and competence to
establish supportive, trusting relationships with people living
with HIV/AIDS and respect for client rights and personal
preferences are essential
Keywords: Anthony L. Jordan Health Corporation, Buffalo , Community Health Worker/RAP, Healthcare , Rochester, New York
