Lead Case Manager Job – Dallas, TX

Prism Health North Texas; Dallas (TX); On-site; USD 42,000 - 66,000; Full time

Job summary

Prism Health North Texas is seeking a Non-Medical Case Manager to coordinate psychosocial support and assist people living with HIV/AIDS in accessing medical and social services. The role involves managing a caseload, developing care plans, and coordinating with medical and community partners across multiple locations.

Responsibilities include needs assessment, eligibility documentation, and ongoing follow-up to promote self-sufficiency and viral suppression, with a focus on housing assistance

Qualifications

• Bachelor's degree in social science or behavioral science, nursing, or a related field.
• Two years of HIV case management experience preferred.
• Texas LMSW or LPC licensure desirable; bilingual in English/Spanish desirable.

Responsibilities

• Coordinate psychosocial support services for people living with HIV/AIDS.
• Maintain a caseload of patients with non-medical case management needs.
• Develop comprehensive care plans with patients and families to improve functioning.
• Perform psychosocial assessments to identify needs in health, mental health, social support, and employment.
• Provide non-medical case management and referral follow-up with documented outcomes.
• Collaborate with medical, mental health, substance use, and community service providers.
• Complete housing assessments and facilitate emergency shelter or housing placements.
• Advocate for services and address barriers to care with problem solving and referrals.

Skills

Excel

Word

Outlook

Empathy

HIV/AIDS knowledge

Education

Bachelor's degree in social science or behavioral science

Two years case management experience preferred

Texas LMSW or LPC licensure desirable

Job description

Why You’ll Love This Job

• Our Core Values:

• We are solution seekers.
• We have a can-do attitude.
• We are mission-driven.
• We care about people.

General Description

The Non-Medical Case Manager coordinates psychosocial support services for people living with HIV/AIDS. The case manager provides a range of client centered activities focused on improving access to and retention in needed core medical and support services the N-MCM provides coordination guidance and assistance in accessing medical social community legal financial employment vocation and/or other needed services. The N-MCM provides case management services at all agency locations, offsite locations within other community-based partner organizations, and curbside/home visits when needed. The N-MCM conducts ongoing needs assessment monitors of care plans documents referring to outcomes to support patients towards self-sufficiency. The case management goal for each patient is to obtain viral suppression through a multi-team approach.

Responsibilities

• Specific Responsibilities of the Job:

• Completes the HIV case management training series for case management annually.
• Completes patient needs assessment to identify unmet psychosocial services needs and determine a case management level/acuity for each patient on caseload.
• Obtains all requisite service eligibility documents, consent, and provides service coordination to support patient access to services.
• Maintains a caseload of patients with documented non-medical case management needs.
• Use the established acuity level and initiate ongoing and regular contact with each patient on caseload to determine needs that have been met, unmet, new needs, and barriers to care.
• Works with patients to develop a comprehensive care plan and set goals in collaboration with patients (including their authorized family, significant others, and other social service providers when appropriate), aimed at increasing the level of functioning and self-sufficiency.
• Performs psychosocial assessments to identify individualized needs in the areas of health, mental health, social support, addiction, financial resources, benefits, legal, language/culture, and employment.
• Provides appropriate and timely non-medical case management and referral follow-up with patients and document referral outcomes.
• Works collaboratively with medical, mental health, substance abuse, and community service providers as well as any authorized member of the patient’s care team.
• Maintains service continuity and eligibility by completing birth month and half birth month eligibility recertification.
• Documents and submit patients ready for case assignments to case management supervisors.
• Follow up with patients and authorized families to ensure that services provided are helpful, appropriate, and adequate.
• Identify emerging barriers and needs and help patients address concerns through problem solving, education, referrals, partnership, and advocacy.
• Regularly review patient’s level of involvement in case management, update care plans, and maintain patient contact in accordance with their level of case management needs.
• Supports patients and providers by reviewing and completing various eligibility forms for medications, social programs, and other funding sources, etc.
• Communicates with each client on a regular basis to determine which needs have been met and to identify any new needs.
• Follows established case management standards of care and agency procedures.
• Completes accurate and timely documentation of all clients encounters as required and submit all necessary reports to supervisor on time.
• Completes an encounter note and log to support patient services delivery daily as proof of daily case management services provided to patients.
• Advocates appropriate services for patients based on needs and assessments.
• Identify patients on caseloads ready for case closure or graduation on a frequent/monthly basis and follow established protocols to close or graduate from non-medical case management.
• Collaborates with the patient, caregivers, and providers to develop a culturally sensitive case management plan that addresses barriers and promotes improved health outcomes.
• Documents each component of the case management process and related activities in accordance with Texas Department of State Health Services (DSHS) Ryan White for service standards and departmental guidelines.
• Maintains concise, accurate, and timely documentation that supports effective and efficient case management services delivery.
• Works with internal teams to prioritize patients for housing services.
• Provides technical assistance to case managers with effective strategies to assist patients experiencing homelessness to access temporary and/or permanent housing.
• Educates case managers about how to complete housing-related documents for housing purposes such as request for documentation assistance, consent to receive mail, and consent to store mail.
• Assists case managers to navigate Homeless Management Information System by providing support for data entry such as general information and Vulnerability Index Scale (VI-SPDAT).
• Attends community partner for Metro Dallas Homeless Alliance meetings such as Rapid Rehousing (RRH), Permanent Supportive Housing (PSH), and Street Outreach.
• Provides support to case managers in this process by relating step-by-step guidelines required by the U.S. Department of Housing and Urban Development (HUD).
• Liaise with The Bridge Homeless Recovery Center by continuing communication with shelter case managers and staff to engage clients living in an entity.
• Collaborates with homeless service providers to connect and engage clients who have been lost to HIV medical care due to housing insecurity.
• Connects with the most vulnerable individuals in the community to maintain relationships in the HIV continuum of care.
• Obtain relevant social history, performance needs and safety assessment as patients enter short- or long-term housing programs.
• Prioritize patients who are at risk of homelessness either through eviction or loss of current housing conditions.
• Completes housing assessments with individuals or families experiencing homelessness.
• Facilitates emergency shelter or hotel placements.
• Provides high-quality, trauma-responsive case management services to patients.
• Manages documentation for third-party housing prioritization into the Homeless Management Information System (HMIS).
• Works with housing partner agencies to prioritize housing services.
• Provides supportive case management to patients living in emergency shelters, encampments, rapid rehousing, or permanent supportive housing.
• Complete offsite visits with patients to verify homelessness in areas such as emergency shelters, domestic violence shelters, encampments, and other areas not meant for human habitation.
• Other duties as assigned.

Skills & Qualifications

Required Knowledge, Skills and Abilities:

• Proficiency in Excel, Word, and Outlook.
• Ability to work in a positive and empathetic manner with people who have HIV/AIDS.
• Working knowledge of medical/psychosocial resources and the medical and psychosocial complexities of HIV/AIDS.
• Demonstrated knowledge and experience working with clients with mental health and substance use disorders.
• Ability to make decisions related to appropriate client care.
• Ability to effectively communicate in verbal and written formats.
• Ability to collaborate with community service providers.
• Ability to establish effective working relationships with clients.
• Ability to manage and work effectively in the required electronic medical record, database, or document portal.
• Ability to work in a multi-site work environment.

Education And Experience

• A bachelor's degree in social science or behavioral science, nursing, or a related field from an accredited domestic or international college or university.
• Two (2) years of experience providing case management for people living with HIV or other chronic conditions preferred.
• Texas licensure (LMSW or LPC) is highly desirable.
• Bilingual in English/Spanish is highly desirable.