CKP Ryan White Medical Case Manager

Community Health Center; Middletown (CT); Hybrid; USD 27,000 - 39,000; Full time

Job summary

Community Health Center is seeking a Medical Case Manager to provide comprehensive, client-centered services to individuals living with HIV/AIDS enrolled in the Ryan White Part B Program. The role involves assessment, care planning, treatment adherence support, and coordination of medical and behavioral health services.

You will collaborate with interdisciplinary teams, maintain required documentation in EHR systems, and advocate to improve access to necessary services.

Qualifications

• Associate degree in Social Work, Human Services, Public Health, or related field.
• Experience in case management, care coordination, HIV services, healthcare, behavioral health, or community-based human services preferred.
• Bilingual English/Spanish is preferred.

Responsibilities

• Conduct comprehensive client assessments to identify medical, psychosocial, behavioral health, housing, financial, transportation, substance use, and other service needs.
• Develop individualized care plans with clients and interdisciplinary providers.
• Maintain monthly contact to monitor progress toward goals and address barriers to care.
• Provide treatment adherence counseling and education on HIV management and prevention.
• Coordinate access to medical care and behavioral health services; facilitate referrals and follow-ups.
• Document encounters, care plans, referrals, and notes within required timelines in EHRs.

Skills

Communication skills

HIPAA compliance

EHR proficiency

Care coordination

Bilingual English/Spanish

Education

Associate degree in Social Work or related

Tools

Electronic Health Records (EHR) systems

Microsoft Office

Job description

Job Description

The Medical Case Manager (MCM) is responsible for providing comprehensive, client-centered Medical Case Management services to individuals living with HIV/AIDS enrolled in the Ryan White Part B Program. The Medical Case Manager supports clients in achieving optimal health outcomes through assessment, care planning, treatment adherence support, linkage to medical and behavioral health services, and ongoing coordination of care.

The Medical Case Manager works collaboratively with interdisciplinary care teams, community providers, and support service agencies to ensure continuity of care and improve viral suppression and retention in care outcomes for clients. Services are delivered in accordance with Ryan White Part B Standards of Care, HRSA/HAB National Monitoring Standards, HIPAA regulations, and Community Health Center policies and procedures.

Role And Responsibilities

Medical Case Management Services

• Conduct comprehensive client assessments within required timelines to identify medical, psychosocial, behavioral health, housing, financial, transportation, substance use, and other service needs.
• Utilize the Ryan White Medical Case Management Triage Model to determine appropriate levels of case management services.
• Develop individualized care plans in collaboration with clients and interdisciplinary providers.
• Maintain ongoing monthly contact with clients to monitor progress toward care plan goals and address barriers to care.
• Provide treatment adherence counseling and education regarding HIV disease management, medications, viral suppression, prevention strategies, and overall wellness.
• Coordinate timely access to medical care, behavioral health services, specialty care, substance use treatment, housing services, transportation, insurance assistance, and other support services.
• Facilitate referrals and follow-up with internal and external providers to ensure continuity of care.
• Monitor client engagement in HIV medical care and support retention in care efforts.
• Conduct reassessments and update care plans at minimum every six (6) months or as clinically indicated.
• Participate in discharge planning and transitions of care in collaboration with supervisors and care teams.
• Advocate on behalf of clients to reduce barriers and improve access to medically appropriate services.

Documentation and Data Management

• Maintain accurate, timely, and complete documentation in electronic health records and required Ryan White data systems.
• Enter all service encounters, care plans, referrals, and case notes within five (5) business days of service delivery.
• Document face-to-face encounters, telehealth visits, phone contacts, referrals, care coordination activities, and treatment adherence services.
• Collect and maintain required Ryan White Part B program data, including:
• Client demographics
• Units of service
• Viral load outcomes
• Hepatitis B and C screening status
• Tuberculosis testing
• Mental health and substance use screenings
• HIV risk reduction counseling
• Participate in Ryan White Services Report (RSR) reporting and other required program reporting activities.
• Ensure confidentiality and compliance with HIPAA, Connecticut HIV confidentiality laws, and organizational policies.

Care Coordination and Community Collaboration

Collaborate with medical providers, nurses, behavioral health clinicians, pharmacists, outreach workers, and community agencies to coordinate comprehensive care.

Maintain active referral relationships with hospitals, public health departments, shelters, behavioral health providers, correctional facilities, HIV testing sites, and community organizations.

Participate in interdisciplinary case conferences, quality improvement activities, and care coordination meetings.

Support clients with benefits counseling and linkage to Medicaid, Medicare, insurance programs, pharmaceutical assistance programs, and other entitlement services.

Quality Management and Compliance

Participate in Clinical Quality Management (CQM) and Continuous Quality Improvement (CQI) initiatives.

Assist with program monitoring activities, audits, corrective action plans, and quality improvement projects.

Attend required Ryan White Part B trainings, provider meetings, and professional development opportunities.

Participate in statewide planning and community engagement activities, including the CT HIV Planning Consortium when assigned.

Maintain compliance with all Ryan White payer-of-last-resort requirements and program eligibility standards.

Caseload Expectations

Maintain a Minimum Active Caseload Of

• 50 clients for Traditional Medical Case Management services
• Complete approximately 1,500 client encounters annually.
• Perform special assignments, projects, and other duties as assigned by the supervisor.

Minimum Qualifications

Education: Associate degree from an accredited college or university in Social Work, Human Services, Public Health, or a related health or human services field.

Experience: Candidates with an associate degree must have a minimum of two (2) years of relevant experience in case management, care coordination, HIV services, healthcare, behavioral health, or community-based human services.

Experience working with individuals living with HIV/AIDS, underserved populations, individuals experiencing housing instability, substance use disorders, mental health challenges, or chronic medical conditions is preferred.

Bilingual English/Spanish is preferred.

Must demonstrate the ability to maintain confidentiality and comply with HIPAA, Ryan White program requirements, and organizational policies and procedures.

Knowledge, Skills, And Abilities

• Strong written and verbal communication, organizational, documentation, and computer skills are required.
• Knowledge of HIV/AIDS treatment, prevention, and Ryan White HIV/AIDS Program services preferred.
• Strong understanding of trauma-informed care, motivational interviewing, harm reduction, and client-centered practices.
• Knowledge of community resources, entitlement programs, and healthcare systems.
• Excellent organizational, communication, documentation, and time-management skills.
• Ability to manage multiple priorities and maintain accurate records in electronic systems.
• Ability to work independently and collaboratively within multidisciplinary teams.
• Ability to maintain strict confidentiality and professional boundaries.
• Proficiency with electronic health records, Microsoft Office, and data management systems.

Physical Requirements

Ability to travel locally for client visits, meetings, outreach activities, and trainings.

Ability to sit, stand, bend, and use office equipment for extended periods.

Ability to occasionally lift up to 20 pounds.

Working Conditions

Work is performed in clinic, community, office, and virtual settings.

Require occasional evening and weekend hours, community outreach, or attendance at off-site meetings and trainings.

Organizational Summary

Location: Middletown - Weitzman Building

City: Middletown

State: Connecticut

Time Type: Full time

Compensation And Benefits

The hourly rate will be 24/hr

At Moses/Weitzman Health System, we are committed to supporting the health, well-being, professional growth, and financial security of our employees. Eligible employees may have access to a comprehensive total rewards package that can include competitive compensation, health and wellness benefits, retirement savings opportunities, paid time off, professional development and tuition assistance programs, employee assistance resources, flexible work arrangements where applicable, and other company-sponsored benefits. Specific benefit offerings and eligibility requirements may vary based on position, work location, scheduled hours, and applicable plan terms. Learn more about our benefits and career opportunities on our Careers website.