Case Manager - Tu Bienestar Program - Part-Time

Casa Esperanza•Boston, MA

178d•$25 - $25

About The Position

The role of the Tu Bienestar Case Manager is to ensure clients are linked to care, engaged in care, and achieve and maintain viral suppression. They will facilitate access to and coordination of needed services for HIV+ clients, including medical and dental care, prescription services, medical treatment compliance, enrollment in the Massachusetts HIV Drug Assistance Program, and mental health/substance abuse counseling, and social services. This individual will also conduct needs assessments, develop service plans, and complete other related paperwork. The Case Manager will conduct file reviews and track the utilization of services to ensure that benchmarks, timelines, goals, and objectives are being met. They will be responsible for all required reporting and attending any relevant conferences and meetings. As part of the Casa Esperanza, Inc. team, you will provide services in a fully integrated, holistic, and collaborative manner using a team-treatment approach to ensure the coordination of all client services, both across Casa programs and with external providers. This integrated model aims to facilitate clear communication amongst all providers and eliminate duplication of efforts or conflicting approaches to care; detail necessary follow-up and assignments; and ensure wrap-around support services are in place to maximize treatment effectiveness and clinical outcomes.

Requirements

Bilingual (Spanish/English) required
Ability to work both independently and as a member of a team
Experience doing outreach to individuals at risk for HIV, addiction, mental illness, trauma, and violence
Crisis management skills
Ability to provide HIV education, group facilitation, service planning, and health navigation
Knowledge of care coordination and community resources
Familiarity with the substance use field, including Motivational Counseling, Cognitive Behavioral Theory, AA/NA 12 Step Philosophy, and Stages of Change Theory
Knowledge of co-occurring disorders
Strong writing, interpersonal, and organizational skills.
Strong verbal and written communication skills
Valid Massachusetts Driver’s License required
Computer skills, minimum Microsoft Word
Experience in group facilitation
Awareness of the intersection of culture, addiction, mental illness, trauma, health, and homelessness
Ability to meet the physical and training requirements of the position
High School Diploma or Bachelor’s degree in social work, psychology, counseling, or other human services-related field preferred (or comparable experience)
Minimum of 3 years’ experience providing Case Management services (or comparable experience)
Certified Alcohol and Drug Counselor/Certified Alcohol Counselor required or willing to obtain within one year of hire
CPR/first aid, NARCAN training, or willingness to get certification in three months

Responsibilities

Coordinate admissions and intakes for Ryan White clients, including liaising with internal and external programs
Ensure all clients meet eligibility for Part A services and document eligibility in the client record
Conduct initial assessment and reassessments for each client and generate individualized service plans that reflect each client’s unique strengths, needs, abilities, and preferences, as appropriate
Conduct periodic reassessments of the ISP, including review of the utilization of services and client-specific advocacy
Assist clients in choosing a Primary Care Provider, making their first appointment, and obtaining health insurance
Communicate directly with medical personnel to educate them about the client’s substance abuse issues, address any concerns, and work collaboratively to meet the client’s needs
Coordinate access to medically appropriate levels of health care, behavioral health services, and other support services to ensure continuity of care
Provide onboarding and annual training for all staff regarding the fundamentals of HIV/AIDS, HIV medications, and strategies for personal risk reduction
Follow up and attend the EHE (Ending HIV Epidemic) request and follow up with the RW Team
Attend and participate actively in the monthly meeting with the Boston Public Health Commission (BPHC) as needed
Participate and coordinate any Quality Improvement (QI) project for the RW program
Help clients navigate entitlement and ancillary service systems to obtain necessary benefits, such as SSI, transportation, health insurance, and dental care
Coordinate internal referrals to on-site services, including GED/ESL education, peer support groups, mental health counseling, and vocational opportunities
Coordinate client transportation as needed
Follow-up calls to maintain client engagement and re-engagement
Develop aftercare plan with clients prior to discharge
Basic use of new work methods using appropriate technologies to provide telehealth services to clients as needed
Collaborate with other agencies, public organizations, and external personnel
Represent the agency by providing education and participating in community events, including street outreach and other agency marketing strategies
Facilitates monthly in-reach meetings at Casa Men’s Program and Latinas y Niños Center to organize and provide HIV education and information about services available for PLWHA at FUOP
Maintain up-to-date contacts for key resources in Evolv and ensure the team is trained to leverage these organizational linkages to support client access to care
Ensure the program is meeting state and federal standards of care and reporting requirements
Develop and maintain a tracking system to ensure client utilization meets program goals and objectives
Work closely with the Multidisciplinary team to ensure that the client’s treatment and service plans are implemented and client needs are being met, as well as presenting client on a ongoing basis
Attending all relevant case conferences and staff meetings as needed
Document all client encounters and other data as required and maintain up-to-date client records
Conduct weekly case file reviews to ensure all documentation is in compliance with state and federal regulations
Ensure E2Boston and Evolv data is entered accurately and in a timely manner
Ensure all documentation for client transportation assistance is reconciled and submitted to the Finance Department for billing
Complete and submit all required reports for Part A services jointly with the team
Other duties as required to support the functions of the program