Medical Case Manager - Ryan White

Legacy Community Health•Houston, TX

1d•Hybrid

About The Position

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.

Requirements

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.
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.
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.

Nice To Haves

A degree in health, human or education services is strongly preferred.
Experience working among the gay, lesbian, bisexual and transgender community is preferred.

Responsibilities

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.
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.
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.