LMSW Medical Case Manager - Ryan White

Legacy Community Health; Houston (TX); On-site; USD 55,000 - 75,000; Full time

Benefits offered by this job

Paid Time Off & Holidays

Medical, Dental, Vision & Life Ins.

Flexible Spending Account (FSA)

403(b) Retirement Plan with Company 1%

Short-Term & Long-Term Disability

$0 Copay for Legacy Provider visits

$0 Copay for prescriptions at LegacyPh

Travel Insurance

Subsidized Gym Membership

Job summary

Legacy Community Health is seeking a Medical Case Manager - Ryan White to provide compassionate psychosocial support for HIV-positive patients. You will work with patients, families, and partners to ensure access to care, resources, and self-management.

The role emphasizes coordination within a primary care home and a team-based approach. Responsibilities include client screening, referrals, and advocacy to minimize service gaps, with travel between Houston and Beaumont as needed.

Qualifications

• Master’s degree in social work is required.
• Current Texas LMSW license is required.
• Bilingual in English and Spanish is required.

Responsibilities

• Identify and screen HIV+ individuals referred for social service needs.
• Provide information and referrals to medical, psychosocial, and basic needs services.
• Advocate to decrease service gaps and remove barriers to services.
• Assist patients who have been lost to care in returning to medical services.
• Document services in EHRS within 72 hours.

Skills

Excellent communication

Bilingual English/Spanish

EHRS proficiency

Multi-tasking

Travel between locations

Education

Master’s degree in social work

Tools

EHRS system

Job description

• Paid Time Off & Paid Company Holidays
• Medical, Dental, Vision & Life Insurance
• Flexible Spending Account (FSA)
• 403(b) Retirement Plan with Company Match
• Short-Term & Long-Term Disability
• $0 Copay for Legacy Provider visits
• $0 Copay for prescriptions filled at Legacy Pharmacies
• Travel Insurance & Pet Insurance
• Subsidized Gym Membership
• And much more!

Location: Legacy Montrose - 1415 California St. Houston, TX 77006

Medical Case Manager - Ryan White (Job Overview)

Schedule: Monday-Friday (8AM-5PM)

Join our family as a Ryan White Medical Case Manager and help HIV-positive patients access the care, resources, and encouragement they need to move toward greater independence and improved overall health. In this meaningful role, you will work closely with Legacy providers, patients, families, and community partners to provide compassionate psychosocial services that address both medical needs and everyday challenges.

Your work will help patients remain connected to care, navigate available services, overcome barriers, and build confidence throughout their healthcare journey. If you are a caring professional who believes every person deserves respectful, coordinated, culturally sensitive support, this is an opportunity to make a lasting difference in community healthcare.

Your Impact

• Support HIV-positive patients through case management, care linkages, patient advocacy, medication and visit adherence assistance, and psychological and social support.
• Help patients who have been lost to care reconnect with medical services and continue moving forward.
• Partner with patients and families to promote timely access, continuity of care, appropriate self-management, and whole-person health.
• Work within a primary care medical home and contribute your perspective to a collaborative, team-based care environment.
• Help identify and reduce service gaps so patients can access medical, psychosocial, and basic-needs resources.

A Collaborative Opportunity

• Build meaningful relationships with patients, families, Legacy providers, peers, supervisors, and community organizations.
• Contribute to quality assurance and performance improvement efforts that strengthen patient services.
• Continue growing your skills through required training, ongoing education, community meetings, and professional collaboration.
• Serve patients across locations as needed, including travel between Houston and Beaumont.

Key Responsibilities

• Identify and screen HIV+ individuals who have been referred for social service needs by Legacy providers.
• Provide information, referrals, and assistance with linkage to medical, psychosocial, and basic needs services as needed with the goal of improving patients’ independence and overall health.
• Advocate on behalf of clients to decrease service gaps and remove barriers to services.
• Assist patients who have been lost to care with returning to medical services.
• Must comply with the standards of care including DSHS Texas HIV Management Standards and other applicable standards of care.
• Follow program standards and protocols, including completing Comprehensive Assessments and Individualized Care Plans with patients.
• Maintain paperwork and documentation necessary for program standards.
• Attend trainings and community meetings as needed.
• Monitor the efficacy and quality of services through periodic re-evaluation with peers and assigned supervisor.
• Document service provided in EHRS client records within 72 hours.
• Participate in Legacy’s Performance Improvement and Quality Assurance Program.
• Demonstrate respect and regard for the dignity of all patients, families, visitors and fellow employees to ensure a professional, responsible and courteous environment.
• Promote effective working relations and work effectively as part of a team to facilitate the department’s ability to meet its goals and objectives.
• Attend required training and ongoing education offered by the agency, including but not limited to safety training and education sessions on Universal Precautions.
• Must be able to travel between locations as needed, including the ability to travel between Houston and Beaumont.
• Work within the context of a primary care medical home, applying a team-based approach to care while working in partnership with patients/families to promote timely access to care, understanding of patient care that is culturally sensitive and language appropriate, continuity of care, and the improvement of the whole-person through the teaching of appropriate self-management skills.
• Perform other duties as assigned.

Minimum Qualifications

• Master’s degree in social work is required.
• Current Texas Licensed Master of Social Work (LMSW) is required. All licensed professionals must maintain their professional licenses as defined by their respective Texas licensing/examining boards.

Required Years of Experience

• One year of case management experience with people living with HIV and/or persons with a history of mental illness, homelessness, or chemical dependence is required.

Desirable Education and/or Experience

• A degree in health, human or education services is strongly preferred.

Required Knowledge, Skills, and/or Abilities

• Excellent communication skills and customer service skills.
• Requires a working knowledge of community resources and treatment issues related to HIV.
• Must be able to manage multiple deadlines and prioritize.
• Demonstrated competency with an EHRS system.
• Ability to multitask in a fast-paced environment.
• Above average organizational skills.
• Strong typing and computer skills.
• Must be able to travel between locations as needed.
• This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management.
• Bilingual (English/Spanish) is required. If the employee is bilingual, then they must have written and verbal fluency in English and Spanish.

Desirable Knowledge, Skills, and/or Abilities

• Experience working among the gay, lesbian, bisexual and transgender community is preferred.

About Legacy Community Health

The largest Federally Qualified Health Center (FQHC) in Southeast Texas, Legacy Community Health has delivered affordable, high-quality care for nearly 40 years across 50+ clinics in Greater Houston and the Gulf Coast. Our mission — driving healthy change in our communities — guides everything we do, and it starts with our people.

Approachable & Collaborative — Leads with humility, values diverse perspectives, and builds trust through teamwork.

Driven & Committed — Takes initiative and goes the extra mile to improve patient outcomes and drive continuous improvement.

Thoughtful Communicators — Pairs clinical/technical skill with emotional intelligence, navigating complex situations with empathy and professionalism.