Ryan White Case Manager

Thundermist Health•Woonsocket, RI

About The Position

The Ryan White Non-Medical Case Manager is a patient-facing role responsible for coordinating comprehensive, non-medical case management services for Ryan White patients (medical and dental). This role focuses on identifying and addressing barriers to care, including housing instability, transportation needs, food insecurity, behavioral health needs, and access to insurance or financial resources. The Case Manager conducts patient assessments, develops individualized care plans, and coordinates referrals to internal and external community resources. This position supports patient enrollment and re-enrollment in Ryan White and related programs, ensuring all eligibility requirements and documentation are complete, accurate, and up to date. Through a client-centered, relationship-based approach, this role plays a critical part in improving patient engagement, retention in care, and overall health outcomes. The Ryan White Non-Medical Case Manager works collaboratively with the Ryan White team, multidisciplinary care teams, community partners, and internal staff to address social determinants of health, remove barriers to care, and ensure patients remain connected to medical and supportive services. Responsibilities include maintaining accurate and timely documentation in required systems, tracking referrals to ensure completion, and conducting outreach and re-engagement efforts for patients at risk of falling out of care. This role supports program goals by ensuring compliance with Ryan White program requirements and contributing to quality improvement initiatives. The position requires obtaining an HIV Case Manager certification to support the delivery of evidence-based, client-centered care and demonstrate specialized knowledge in HIV and behavioral health. This certification enhances the ability to address barriers to care, improve treatment adherence, and strengthen patient engagement and outcomes.

Requirements

BA/BS in a clinical/healthcare or related field (Social Work, Public Health, Nursing, Psychology) required, or relevant industry specific experience considered in lieu of college degree where possible.
Two or more years of patient care experience in a health care environment include case management, care coordination, or social services.
Experience with multidisciplinary care teams, and involvement with complex programs required.

Nice To Haves

HIV Case Manger Certification (or equivalent) is preferred.
Behavioral Health Case Manager Certification (or equivalent) is preferred.
Clinical/ambulatory care setting preferred.
FQHC experience preferred.
HIV Case Manger Certification (or equivalent) is preferred.
Familiarity with the Ryan White HIV/AIDS Program and understanding of the challenges faced by the target population.
Bilingual or multilingual abilities.
Familiarity with clinical quality improvement methodologies.

Responsibilities

Provide comprehensive non-medical case management to Ryan White patients, addressing barriers to care including transportation, housing, food insecurity, behavioral health, medication, insurance, and financial challenges
Conduct proactive outreach and engagement, including wellness checks, to support patients at risk of falling out of care and assist with re-engagement
Assist patients with navigating community resources and initiating referrals to external agencies (e.g., housing, behavioral health, financial assistance), including partners such as Agape, ACOS, and APRI
Facilitate and track referrals to ensure patients attend appointments and receive necessary services
Assist in clinical quality assurance by reaching out to non-compliant patients to schedule appointments and improve adherence.
Manage Ryan White program enrollment and re-enrollment (medical & dental), ensuring all required documentation is obtained and maintained
Enroll and support patients in ADAP, RIFAB, and health insurance programs (as applicable)
Conduct Health Insurance Enrollment as a Certified Navigator and attend required Navigator meetings
Complete monthly tracking forms for patients assisted as a Navigator
Enroll eligible patients in ADAP through Lifia and RIFAB as needed
Investigate patients’ insurance benefits coverage for specialty medications requiring prior authorization
Collect invoices or bills from patients in need of financial assistance per Ryan White allowable costs
Collaborate within the Ryan White program team to ensure coordinated, patient-centered care
Participate in HIV multidisciplinary team meetings and community partnership meetings to ensure continuity of care
Coordinate with and schedule delivery of HIV medications with partnering pharmacies/specialty pharmacies
Work with the clinical quality and reporting teams to ensure accurate lab tracking and obtain outside results as needed
Assist with Telephone Encounters for the Ryan White team as needed
Maintain accurate and timely documentation in CAREWare, the electronic health record, and other required systems
Support reporting, tracking, and compliance requirements for Ryan White program standards
Ensure documentation meets regulatory and program expectations
Attend conferences, workshops, state-recipient meetings, HIV Case Manager meetings, CAB events, and relevant trainings
Assist with Ryan White dental team operations including training, re-enrollment, scheduling, referrals, transportation, and billing support
Participate in community partner collaborations and organizational initiatives
Provide additional support and complete special projects as assigned by Ryan White leadership