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Linkage and Retention Coordinator at NeighborHealth Corporation in East Boston, Massachusetts

Posted in General Business 30+ days ago.

Type: Full-Time

Job Description:

Thank you for your interest in a career at NeighborHealth, formerly East Boston Neighborhood Health Center!

Everywhere you turn, you can feel the immeasurable level of enthusiasm here at NeighborHealth! We are one of the largest community health centers in the country, supporting the greater Boston area and focusing on the well-being of our patients and local community. From the nurses and physicians on the front line of patient care, to the managers who lead and guide our staff, to the many support roles that keep our facilities running smoothly - everyone plays a vital role in improving medicine for our patients.

Interested in this position? Apply online and create a personal candidate account!

Current Employees of NeighborHealth- Please use our internal careers portal to apply for positions.

To learn more about working at NeighborHealth and our benefits, please visit out our Careers Page.

Time Type:

Full time


Project Shine

All Locations:

East Boston


Coordinates linkage and retention services funded through DPH/OHA focusing on the most vulnerable, at-risk patients experiencing challenges with a new HIV diagnosis, linkage & retention in care, medical adherence, and viral load suppression. Provides supportive outreach efforts to patients who have received a new HIV diagnosis, have fallen out of care and/or are at risk of disengaging from care, have detectable viral loads, and/or have missed medical visits. Promotes team and collaborative work and serves as a key member of the clinical care team. Is responsible for reporting, documentation, and utilization of resources. Reports to Department Manager.

Essential Duties & Responsibilities       

  • Coordinates and oversees DPH/OHA ARCH/Linkage and Retention funded services & objectives and ensures compliance with funder requirements and expectations.

  • Coordinates and leads patient linkage and retention initiatives with support from admin team.

  • Leads, supports, and supervises linkage & retention team.

  • Will participate in quality assurance and quality improvement efforts.

  • Sets goals for performance and deadlines to comply with program and funders expectations.

  • Provide weekly status report on successes, challenges, barriers, and service delivery progress to Department Manager.

  • Completes work plan for upcoming fiscal year, setting realistic projections based on previous performance year and current service trends.

  • Completes monthly call DPH report and actively participates in monthly monitoring call with DPH/OHA.

  • Ensures proper documentation is entered in electronic medical record and care ware system in a timely manner.

  • Will participate in recruitment, interviewing, orienting, and training of new linkage & retention staff.

  • In collaboration with department leadership, will provide feedback to linkage & retention staff and will participate in annual performance review of staff.

  • Will support team/staff development efforts to ensure that each team member is performing at their best level.

  • Responsible for managing and addressing DPH patient list.

  • Will identify training needs for linkage team and communicate with department leadership.

  • Provide intensive retention and outreach services to approximately 35 highly vulnerable, at risk patients

  • Provide supportive linkage and retention services. that will involve an enhanced focus on medication adherence support, health literacy, de-briefing medical appointments, support in attendance at medical appointments, including accompaniment as requested, and help to follow up on referrals. 

  • Assist in completing the HIV/AIDS services acuity tool at intake into services and at 3-month intervals for 12 months.  Document results and sources of assessment information in client electronic record.

  • Complete the Individual Service Plan (ISP) with the client, as indicated by DPH/OHA.

  • Provide services to each client for 6 months, with a potential extension based on acuity level.

  • For clients transitioned to routine Medical Case Management (MCM), monitor for an additional 6 months.

  • Facilitate weekly Linkage and Retention Meeting.

  • For patients unable to come into the clinic, meets patients in non-clinical settings, including home, adhering to safety protocols.

  • Document successful linkage to care (as applicable) by tracking medical visits and noting client attendance at medical visits

  • Document all referrals and interactions with and about patients in the electronic record.

  • Communicate with primary care and other team members regularly regarding patient status

  • Actively participates in weekly clinical care team meetings.

  • Attends required staff meetings, team Huddles, and leadership meetings, as appropriate

  • Attends funder required meetings, events, and/or trainings.

  • Prepares for and participates in annual monitoring site visits and effectively addresses any recommendations/findings.

  • Participate in required clinical and administrative supervision.

  • Provide documentation for grants, projects, etc. as directed by supervisor.

  • Participate on intra-agency committees

  • Ensures a safe, secure and legal work environment.

  • Attend trainings on regular basis as recommended by supervisor, organization, and/ or funders.

  • Other Job Duties and projects assigned


  • BA/BS preferred.  Community Health Worker or DPH/JRI certificates a plus.

  • MA Driver’s License and ability to provide transportation to CBO’s highly desirable.


  • Minimum of two years of experience in community health, supervising and leading teams (includes supervisory in any industry), working with socially, economically, culturally diverse populations.

  • Experiencing working with individuals living with HIV and complex care coordination.


  • Good understanding of substance abuse, risk behavior and cultural issues.

  • Good assessment and counseling skills.

  • Bilingual/bicultural in Spanish or Portuguese strongly preferred.

  • Excellent interpersonal skills.

  • Good verbal and written communication skills.

  • Experience in Microsoft Word and Access.


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