HIV Case Manager - Non-Medical

The Montrose Center•Houston, TX

About The Position

The HIV Case Manager - Non-Medical role focuses on screening clients for eligibility for Ryan White services, conducting comprehensive non-medical assessments, and developing individualized service plans. The position involves providing ongoing case management, advocacy, and coordination of services to help clients access HIV care, supportive services, and address barriers such as transportation, housing, food insecurity, and financial hardship. The role also includes connecting clients to substance-use treatment, behavioral health services, and other community resources, while maintaining accurate records and collaborating with partner agencies.

Requirements

High school diploma or equivalent required.
Experience providing case management, care coordination, social services, community outreach, or client support.
Strong communication, organizational, documentation, and problem-solving skills.
Ability to work effectively with individuals from diverse cultural, socioeconomic, and personal backgrounds.
Ability to work independently and collaboratively as part of a multidisciplinary team.

Nice To Haves

Associate or bachelor's degree in social work, human services, public health, behavioral health, psychology, sociology, or a related field preferred.
Experience working with individuals or communities affected by HIV, substance use, homelessness, behavioral health concerns, or other social determinants of health preferred.
Experience working within the Ryan White HIV/AIDS Program or another HIV service program preferred.
Knowledge of HIV care, supportive services, and barriers to HIV care preferred.
Experience with substance-use treatment, recovery services, harm reduction, or behavioral health programs preferred.
Familiarity with local housing, transportation, food, insurance, benefits, and financial-assistance resources preferred.
Experience working with individuals experiencing homelessness or housing instability preferred.
Bilingual or multilingual skills relevant to the population served preferred.

Responsibilities

Screen clients for eligibility for Ryan White services and perform necessary 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.