System Navigator – HIV Support Program

Positive Living Niagara is a community-focused organization composed of passionate staff and volunteers. We champion client advocacy, harm reduction and inclusive care by meeting people where they are, dismantling barriers and fostering strong community partnerships. Together, we support individuals living with or affected by HIV and/or substance use by reducing stigma, promoting health and creating safe, welcoming spaces for healing and connection.
The System Navigator provides client-centered support to individuals living with HIV and who may experience barriers to accessing health and social service systems. Through practical support, case management, education and coordination, the System Navigator assists individuals in navigating complex service systems while promoting dignity, autonomy, and equitable access to care.
Working collaboratively with healthcare providers, community organizations, and multidisciplinary partners, the System Navigator promotes timely access to HIV care and treatment, enhances continuity of care, and supports clients in achieving their self-identified goals while maintaining dignity, autonomy, confidentiality, and equitable access to services.
Key Responsibilities:

1.Care Coordination & Clinical Navigation

Build collaborative relationships with HIV clinics, hospitals, primary care providers, public health, pharmacies and community organizations.

Coordinate transitions between hospital, primary care, pharmaceutical and community services.

Make direct referrals for HIV clinical care and treatment and coordinate follow-up with HIV specialists, primary care providers and allied health professionals.

Support clients in maintaining meaningful engagement in HIV care while identifying and responding early to barriers that may contribute to dis-engagement.

Facilitate client enrolment with primary care providers.

Facilitate communication among service providers while maintaining client confidentiality and informed consent.

Maintain current knowledge of HIV treatment, prevention strategies and community resources.

Assist clients in understanding available treatment options and community supports.

2.Client Support & System Navigation

Conduct client-centered assessments and identify barriers to services.

Provide time-limited case management for identified clients, using individualized Support Plans based on client’s self-identified goals.

Review client goals, progress, and support need collaboratively at least every three months, or more frequently as needed, and update support plans to reflect changing priorities and circumstances.

Assist clients in navigating social services, healthcare, housing, legal, income support, and immigration systems.
Provide transportation and accompaniment to clients accessing health and social services as required,
within agency parameters.

Provide support with applications, forms, appointments, and service referrals to Ontario Works, ODSP,
housing services, identification replacement, immigration documents, healthcare, mental health, harmreduction service, addictions services and any other needs identified by client.

Facilitate warm transfers to internal programs, community agencies and service providers.
Provide crisis intervention and problem-solving support as required.

Deliver information related to HIV, HCV, STBBIs, safer substance use, and overdose prevention.
Provide supportive counselling and brief interventions related to HIV status, HIV care, mental health, and
social determinants of health.

Work collaboratively with internal and external service providers to ensure coordinated care.
Foster collaborative relationships and strengthen referral pathways to improve coordination across the
health and social service system.

Work with agency leadership to advocate for equitable access to services and systemic improvements for
people living with HIV.

Promote inclusive principles and challenge stigma associated with HIV and harm reduction strategies.
Support clients in making informed decisions regarding their health and well-being through culturally safe,
trauma-informed, and person-centred approaches that honour each client’s cultural values, beliefs,
traditions, and lived experiences.

Provide evidence-based education related to HIV, treatment adherence, prevention, sexual health and harm
reduction.

Participate in community committees, planning tables, working groups, and collaborative initiatives as
assigned.

Maintain awareness of emerging trends, service gaps, and community needs and communicate findings to
the Supervisor and broader team to support program development and advocacy efforts.

3. Caseload Management & Client Assignment

Each client receiving ongoing support will be assigned a Primary System Navigator who is responsible
coordinating services, maintaining documentation, monitoring progress toward client-identified goals, and
acting as the primary point of contact for the client.

The System Navigator team serve as backup support for all active clients and may provide support, advocacy,
follow-up, transportation assistance, outreach, or case management coverage when the Primary System
Navigator is unavailable.

All System Navigators are expected to maintain familiarity with active client files and participate in regular
case reviews to ensure continuity of care across the program.

Referrals received will be directed to the Care Coordination Supervisor and assigned to System Navigators
based on factors including:

Current caseload capacity,
Complexity of client needs,
Existing service relationships,
Geographic considerations; and
Program priorities.

Caseload assignments will be reviewed regularly through supervision, file audits and team meetings to
ensure equitable workload distribution and effective client support.

4. Documentation, Data Collection & Quality Assurance
• Maintain client records in accordance with agency policies, funder requirements, and professional
standards.
• Complete assessments, support plans and referrals within established timelines. Case notes and follow-up
documentation must be completed within 24–48 hours of client interaction.
• Utilize TREAT Database for client documentation, case management activities, progress notes, goal tracking,
and statistical reporting.
• Create and maintain client files according to program standards and consent requirements.
• Upload and maintain all relevant supporting documentation to TREAT database including consents,
identification, referrals, and other client-related records within 24-48 hours of receiving.
• Participate in Case Management file audits and case reviews.
• Assist in maintaining accurate active client lists and caseload records.
• Track service statistics and outcome measures mandated by agency and funder requirements.
• Ensure confidentiality and compliance with privacy legislation (PHIPA), agency policies, and documentation
standards.
• Contribute to data collection initiatives that support program evaluation and continuous quality
improvement.
• Complete agency assigned trainings.

5. Program Development, Team Collaboration & Administrative Responsibilities
• Attend and actively participate in agency meetings, department meetings, team meetings and weekly support
huddles.
• Ensure all required administrative documentation for transportation remains up to date on all agency
platforms. E.g. ODSP Mandatory Special Necessities (MSN) Benefit Application.
• Participate in professional development opportunities and required training.
• Maintain knowledge of community resources and update resource information as required.
• Contribute to shared resource calendars, maintain accurate information within the shift plan and other
information systems.
• Utilize Teams, shared drives, and agency communication platforms to support collaboration and information
sharing.
• Assist with service coverage across agency programs when operationally required.
• Participate in program planning, evaluation, and quality improvement initiatives.
• Support and promote Positive Living Niagara events, education sessions, and community engagement
activities.

Organizational Responsibilities:
• Adhere to the Mission, Vision, Values and Policies of Positive Living Niagara.
• Represent the agency in a professional, ethical, and respectful manner.
• Promote teamwork, collaboration, and effective communication.
• Foster inclusive, anti-oppressive, trauma-informed, and culturally responsive practices.
• Maintain professional boundaries and confidentiality.
• Demonstrate reliability, accountability, and commitment to scheduled work hours and assigned
responsibilities.
• Support a workplace culture that values harm reduction, dignity, respect, equity, diversity, and inclusion.
• Assist with the coordination and delivery of other Positive Living