Case Manager, Community Based Services

Job Description Summary:

Job Description:

The Ryan White Part B (RWB) Medical Case Manager at the Center for Key Populations (CKP) coordinates care for HIV-positive individuals. This role provides client-centered services to ensure linkage to healthcare, including behavioral health, dental, substance use treatment, and other community resources. The Case Manager works closely with clients to support treatment adherence, care coordination, and continuity of services, aiming to achieve viral suppression through a multidisciplinary team approach.

This position carries a caseload of up to 50 clients and involves comprehensive service planning, goal setting, and resource identification, as mandated by the RWB grant. The Case Manager collaborates with community partners to facilitate access to essential services aligned with each client’s individualized care plan.

Role and Responsibilities:

• Monitor and implement the goals and objectives of the RWB grant to ensure project success.
• Conduct client assessments to evaluate service needs, motivation, strengths, medication adherence, and understanding of HIV disease.
• Identify and address barriers to medication and treatment adherence.
• Develop and manage comprehensive, individualized care plans for each client.
• Maintain ongoing contact and follow-up with clients to support care coordination.
• Provide ongoing patient education tailored to individual healthcare goals, complementing PCP/HIV provider treatment plans.
• Ensure timely and coordinated access to medically appropriate health and support services to maintain continuity of care.
• Deliver medical case management for up to 50 clients in accordance with RWB grant guidelines and HRSA/HAB standards of care.
• Establish and maintain a strong network of community partners to enhance available resources for clients.
• Assist in implementing project activities, including community events, social media campaigns, outreach to community partners, service promotion, research initiatives, and dissemination efforts.
• Manage client documentation, maintain charts, enter data, and utilize internal and external programmatic systems effectively.
• Complete triannual reports as requested by funders.
• Actively participate in CKP staff meetings, quality management and improvement projects, program-specific meetings, and organizational and community meetings as directed by the supervisor.
• Facilitate a Peer Support Group once a week.
• Be available for evening and weekend work as required.
• Perform special assignments, projects, and other duties as assigned by the supervisor.

Qualifications:

• Bachelor’s degree in Public Health, Human Services, Social Work, or a related field (preferred) OR equivalent experience in case management and/or HIV-related services.
• Knowledge of HIV/AIDS treatment, care, and support services.
• Experience with client-centered service planning, care coordination, and case management.
• Strong interpersonal, communication, and organizational skills.
• Ability to establish and maintain relationships with community organizations.
• Proficiency in electronic health records (EHR) and documentation requirements.
• Commitment to working with diverse populations, including individuals with substance use disorders, mental health conditions, and those experiencing housing instability.
• Reliable transportation is essential.
• Bilingual skills (preferred but not required).

PHYSICAL REQUIREMENTS/WORK ENVIRONMENT

At times, staff will enter organized and supportive housing environments and are required to climb up and down stairs. Most of the time, staff is expected to be in the office or at community agencies doing collateral work with or on behalf of the consumer. Community events are also a requirement of this position. Travel time by foot or automobile is required.

Organization Information:

The Moses/Weitzman Health System is a global leader addressing challenges faced by organizations caring for the poor and diverse populations, and is home to programs focusing on education, research, and process improvement support for safety net providers. The system delivers primary care to more than 150,000 patients in Connecticut, and extends access to specialty care for more than 2.5 million individuals across the U.S. It is a national accrediting body for organizations training advanced practice providers, and offers accredited education and training for Medical Assistants in multiple states. As an incubator for new ideas in areas including social justice, the environment, and social determinants of health, the MWHS is addressing challenges faced by providers caring for underserved communities, creating innovative and impactful initiatives led by nationally and internationally recognized experts. As it forges pathways into the future of primary care, the MWHS honors Lillian Reba Moses (1924-2012), a granddaughter of slaves, and Gerard (Gerry) Weitzman (1938-1999), whose ancestors escaped pogroms in Eastern Europe. Their vision and commitment to justice and equity in healthcare is the foundation upon which the Moses/Weitzman Health System was built.

Location:

Middletown - Weitzman Building

City:

Middletown

State:

Connecticut

Time Type:

Full time