Case Manager - Tu Bienestar

About Casa Esperanza

Casa Esperanza, Inc. is a bilingual/bicultural behavioral health treatment provider serving Boston and the Merrimack Valley. Our mission is to empower individuals and families to recover from addiction, trauma, mental illness, and other chronic medical conditions; overcome homelessness and discrimination; and achieve health and wellness through comprehensive, integrated care.

About the Role

The Tu Bienestar Case Manager ensures clients are linked to care, engaged in care, and achieve and maintain viral suppression. They 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, mental health/substance abuse counseling, and social services. This role involves conducting needs assessments, developing service plans, and completing related paperwork. The Case Manager tracks service utilization to ensure benchmarks, timelines, goals, and objectives are met, handles required reporting, and attends relevant conferences and meetings.

As part of the Casa Esperanza team, you will provide services in a fully integrated, holistic, and collaborative manner using a team-treatment approach to coordinate all client services, both across Casa programs and with external providers. This model facilitates clear communication among providers, eliminates duplication of efforts, and ensures wrap-around support services to maximize treatment effectiveness and clinical outcomes.

Responsibilities

• Case Management
  • 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 assessments and reassessments for each client and generate individualized service plans reflecting each client’s unique strengths, needs, abilities, and preferences
  • Conduct periodic reassessments of the ISP, including review of service utilization 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 concerns, and collaborate 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 on EHE (Ending HIV Epidemic) requests and coordinate with the RW Team
  • Attend and participate actively in monthly meetings with the Boston Public Health Commission (BPHC) as needed
  • Participate and coordinate any Quality Improvement (QI) project for the RW program
• Bilingual Wellness Group and Client Education
  • 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
  • Conduct follow-up calls to maintain client engagement and re-engagement
  • Develop an aftercare plan with clients prior to discharge
  • Provide general backup support for intakes at the Familias Unidas Outpatient Program
  • Use appropriate technologies to provide telehealth services to clients as needed
  • Perform other case management-related duties to support the program
• Outreach/In-Reach
  • 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
  • Facilitate 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
• Administrative
  • 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 meets 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 client treatment and service plans are implemented and client needs are met
  • Attend all relevant case conferences and staff meetings as needed
  • Document all client encounters and maintain up-to-date client records
  • Conduct weekly case file reviews to ensure 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
  • Perform other duties as required to support the functions of the program

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

Qualifications

• High school diploma or bachelor's degree in social work, psychology, counseling, or another 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 willingness to obtain within one year of hire
• CPR/first aid, NARCAN training, or willingness to get certification within three months

Benefits

• Compensation: $24.52-25.00/hour
• 401(k) Retirement Plan: All eligible employees may elect to participate after 1 year of service. Casa Esperanza, Inc. will match a contribution of up to 6% of your annual salary
• Holiday Pay: 12 days per year + 1 floating holiday
• Paid Time Off (PTO): 18 days in year one, 20.5 days in year two, 23 days in year five
• Sick Pay: 10 paid days per year
• Long/Short-Term Disability: Paid by Company
• Life Insurance
• Health Insurance: Medical, Dental, Vision
• Health Reimbursement Arrangement (HRA)
• FSA/DCA: Flexible Spending Account & Dependent Care
• ComPsych Guidance Resources - EAP
• Educational Opportunities
• Tuition Remission
• Employee Ticket at Work: Discounts for Entertainment, Travel, Movies, etc.
• Career Advancement Opportunities
• Increased Salary for Credentials

Schedule

This role follows Casa Esperanza’s standard schedule and operational hours, with specific expectations for attendance at monthly BPHC meetings, in-reach meetings, and other required events.

Physical & Mental Requirements

While performing the duties of this job, the employee is regularly required to walk, stoop, kneel, crouch, or crawl and talk or hear. The employee must occasionally lift and/or move up to 20 pounds. Specific vision abilities required include distance vision, peripheral vision, and depth perception.

All offers of employment are contingent on the candidate showing proof of being fully vaccinated against COVID-19 (currently one dose of the Johnson & Johnson vaccine or two doses of the Pfizer or Moderna vaccine and a booster, when eligible) to pass the pre-employment requirements. Individuals with medical issues or religious beliefs that prevent them from getting the vaccine may request an exemption from the vaccine requirement.