Coordinator, Linkage to Care

About Us:

Serving one million patients and their families annually. Advancing medical knowledge, technologies and practices. Developing and educating the next generation of exceptional health care professionals.

With more than 100 locations in hospital-based clinics, outpatient health and specialty care centers, we provide the most advanced medicine and thoughtful, patient-centric care to the greater metro-Detroit community.

Job Summary:

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.

Job Description:

Essential Functions

(Essential functions are the primary duties/major job responsibilities that an employee must be able to perform, with or without reasonable accommodation. The essential functions are listed in order of importance.)

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.

20%

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.

20%

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.

10%

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.

10%

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.

10%

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.

10%

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.

10%

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.

5%

Perform other related duties as assigned.

5%

MINIMUM QUALIFICATIONS

Education Bachelor's degree

• Bachelor's degree from an accredited college or university in a public or community health-related field.
• Master of Public Health with emphasis on epidemiology and public health clinical practice preferred.

Experience Experienced (minimum 2 years of job-related experience)

• Experience working in an urban environment.
• Experience working in Sexually Transmitted Infections (STI), HIV, tuberculosis, viral hepatitis, or other public health programs.
• Prior supervisory experience preferred.
• Bilingual or multilingual abilities preferred.
• Familiarity with Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS program services, Disease Intervention Services, and surveillance systems.
• Experience with care coordination, case management, or patient navigation.
• Experience working with populations impacted by HIV/, STI, tuberculosis and viral hepatitis.

KNOWLEDGE, SKILLS, AND ABILITIES

• Knowledge of HIV, syphilis, tuberculosis, and hepatitis C transmission, treatment, and prevention.
• Understanding of connection to care, retention and re-engagement strategies and related clinical quality performance metrics.
• Familiarity with healthcare and public health systems.
• Strong interpersonal and communications skills with diverse populations.
• Organizational and time management skills to manage multiple clients and priorities.
• Documentation and data entry skills.
• Ability to work collaboratively with multidisciplinary teams across multiple entities.
• Ability to build rapport and trust with clients using a patient-centered approach.
• Ability to navigate complex systems and advocate for client needs.
• Ability to maintain confidentiality and comply with HIPAA and public health regulations.
• Ability to work independently and as part of a team.

Working Conditions

• This position operates in a hybrid clinical and community-based setting, including office environments, healthcare facilities, and outreach locations such as community organizations or client residences when appropriate.
• May be required to travel locally to conduct outreach and support service coordination.
• Exposure to emotionally challenging situations, including discussions related to chronic illness, stigma, trauma, and health disparities.

Wayne Health is an EEO/AA/Veteran/Disability Employer