HIV Care & Support Services Case Manager

The Montrose Center; Houston (TX); On-site; USD 42,000 - 58,000; Full time

Job summary

The Montrose Center in Houston, TX is seeking an experienced Case Manager to support clients navigating HIV-related services under the Ryan White program. You will conduct assessments, develop individualized plans, and coordinate care across medical, behavioral health, and social services.

Responsibilities include data entry, eligibility screening, follow-up, and advocacy to remove barriers such as housing, transportation, and insurance.

Qualifications

• High school diploma or equivalent required; associate or bachelor's degree in social work, human services, public health, behavioral health, psychology, sociology, or a related field preferred.
• Experience providing case management, care coordination, social services, community outreach, or client support.
• Experience working with individuals or communities affected by HIV, substance use, homelessness, behavioral health concerns, or other social determinants of health preferred.
• Strong communication, organizational, documentation, and problem-solving skills.
• Ability to work with diverse cultural, socioeconomic, and personal backgrounds.
• Experience with Ryan White HIV/AIDS Program or similar HIV service program preferred.
• Familiarity with local housing, transportation, food, insurance, benefits, and financial resources preferred.
• Bilingual or multilingual skills relevant to the population served preferred.

Responsibilities

• Screen clients for eligibility for Ryan White services and perform data entry into TCT, CPCDMS, and EHR.
• Conduct comprehensive non-medical assessments to identify clients' needs, strengths, goals, and barriers to accessing HIV care and supportive services.
• Develop individualized service plans with clients based on their identified needs, preferences, and goals.
• Provide ongoing case management, advocacy, follow-up, and coordination of services.
• Assist clients with navigating the healthcare and social-service systems while promoting self-advocacy and independence.
• Connect clients to HIV medical care, behavioral health services, substance-use treatment, recovery support, and other community resources.
• Support clients experiencing substance-use challenges using a nonjudgmental, person-centered, and harm-reduction approach.
• Provide referrals and linkage to substance-use treatment, mental health services, recovery resources, peer support, and other appropriate services.
• Assist clients with identifying and addressing barriers such as transportation, housing instability, food insecurity, financial hardship, insurance coverage, employment, legal concerns, and lack of identification or documentation.
• Help clients apply for and maintain eligibility for benefits and assistance programs, including health insurance, medication assistance, food assistance, housing resources, and other supportive programs.
• Coordinate referrals and communicate with partner agencies, healthcare providers, and service organizations, with appropriate client authorization and attention to confidentiality.
• Follow up with clients regarding referrals, appointments, service connections, and progress toward established goals.
• Maintain accurate, timely, and confidential case-management records in accordance with agency, Ryan White, HIPAA, and applicable program requirements.
• Participate in multidisciplinary team meetings, case conferences, trainings, and community outreach activities as required.
• Maintain current knowledge of HIV services, substance-use resources, behavioral health services, housing programs, benefits, and other community resources.
• Perform other duties as assigned.

Skills

Case management

Care coordination

Social services

Community outreach

Documentation

Problem-solving

Multilingual/bilingual

Independent & collaborative work

Education

Associate or Bachelor's degree in social work or related field

Job description

The Montrose Center in Houston, TX is seeking an experienced Case Manager to support clients navigating HIV-related services under the Ryan White program. You will conduct assessments, develop individualized plans, and coordinate care across medical, behavioral health, and social services.

Responsibilities include data entry, eligibility screening, follow-up, and advocacy to remove barriers such as housing, transportation, and insurance.