HIV Case Manager

Position Overview

The HIV Case Manager provides client-centered medical case management services to people living with HIV. This role supports timely linkage to care, retention in care, treatment adherence, benefits coordination, and connection to medical and supportive services that improve health outcomes. The HIV Case Manager works closely with providers, nurses, behavioral health staff, peers, and community partners to help clients navigate complex systems of care in alignment with Ryan White Part A Medical Case Management service standards.

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Key Responsibilities

Client Assessment and Care Planning

• Complete initial assessments, reassessments, acuity tools, and evidence-based screening tools to identify medical, behavioral health, social, and support service needs.
• Develop individualized care plans with measurable goals, action steps, and follow-up needs in collaboration with each client.
• Review and update care plans at least every six months, or more often when there is a significant change in the client’s status, needs, or goals.
• Provide client-specific advocacy and problem-solving support to reduce barriers to care and improve engagement.
  
  
  

Medical Case Management and Client Monitoring

• Provide ongoing medical case management through face-to-face visits, phone calls, telehealth, and other approved forms of communication.
• Monitor client progress at least quarterly, or according to acuity and care plan needs, to assess response to services, changes in medical condition, and emerging barriers.
• Support treatment adherence by counseling clients on the importance of medication adherence, laboratory monitoring, routine HIV medical visits, and chronic disease self-management.
• Coordinate discharge planning or step-down in-service intensity when clients have reached goals or no longer require a higher tier of support.
  
  
  

Linkage, Referral, And Benefits Coordination

• Coordinate timely referrals and linkage to HIV medical care, behavioral health, substance use treatment, dental care, housing, transportation, food resources, insurance enrollment, medication access programs, and other supportive services.
• Assist clients with benefits counseling and access to public and private programs for which they may be eligible, including Medicaid, Medicare, marketplace plans, and medication assistance programs.
• Track referral completion and follow up to confirm clients are successfully connected to needed services.
• Work collaboratively with internal teams and external partners to ensure continuity of care across settings.
  
  
  

Documentation, Compliance, and Quality

• Maintain accurate, timely, and complete documentation in the electronic health record, CAREWare, and other required systems.
• Upload and maintain required screening tools, assessments, care plans, progress notes, and discharge documentation according to grant and program requirements.
• Ensure progress notes and service entries are consistent, complete, and compliant with Ryan White Part A Medical Case Management standards, confidentiality requirements, and HIPAA.
• Participate in chart audits, quality improvement activities, case reviews, team meetings, and trainings to support program excellence.
  
  
  

Outreach and Team Collaboration

• Engage clients who are newly diagnosed, out of care, at risk of disengagement, or in need of additional support to remain connected to treatment.
• Collaborate with providers, nurses, health educators, peers, and referral partners to promote coordinated and responsive care.
• Represent The Center professionally in community settings and contribute to service navigation efforts that support people living with HIV.
  
  
  

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Minimum Qualifications

• Minimum of two years of experience in HIV services, case management, healthcare navigation, community health, or a related field preferred.
• Experience working with diverse populations, including LGBTQ plus communities, uninsured or underinsured clients, and people affected by housing instability, stigma, or other barriers to care.
• Experience with grant-funded programs, service documentation, and data systems such as CAREWare and electronic health records preferred.
  
  
  

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Knowledge & Skills

• Strong understanding of HIV care systems, treatment adherence, health disparities, and barriers to sustained engagement in care.
• Ability to provide client-centered, culturally responsive, trauma-informed support and service coordination.
• Ability to develop care plans, maintain organized documentation, meet deadlines, and manage multiple priorities.
• Strong verbal, written, and interpersonal communication skills.
• Proficiency in Microsoft Office and comfort working in electronic records systems.
• Reliable transportation and ability to work from multiple locations as needed.
• Spanish or other language fluency is a plus
  
  
  

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Physical Requirements

• This position may require local travel, attendance at community meetings, and movement between clinic and partner sites.
• The role may involve prolonged periods of sitting, computer work, standing, speaking, and participating in meetings or outreach activities.
• Occasional evening or weekend hours may be required to meet program needs
  
  
  

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Educational/Licensure Requirements

• Bachelor’s degree in social work, human services, public health, healthcare, or a related field. Equivalent direct experience may be considered.
• This position aligns with Tier 2 Medical Case Management service delivery under the Ryan White Part A Medical Case Management standards. Tier 2 services may be provided by a Certified Community Health Worker Level II, a Certified Peer Recovery Support Specialist, and/or a staff member with a bachelor’s degree or above in a human service or medical-related field.
• The HIV Case Manager is expected to deliver services consistent with Tier 2 community-based case management while working as part of the broader clinical care team
  
  
  

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Salary: $52,000 – $57,000 Annually

Benefits:

• 403(b) W/Employer percentage match
• Health Insurance
• Dental
• Vision
• Employee Assistance Program – EAP
• PTO
• Paid holidays
• Floating Holidays
• Birthday time