Ryan White Case Manager

About the Role

The Ryan White Case Manager provides various levels of case management assistance to individuals living with HIV, addressing barriers such as understanding diagnoses, medication adherence, mental health, housing instability, food insecurity, and other challenges that impact their ability to maintain care and viral suppression. As a client advocate, the Case Manager conducts assessments, identifies client-specific needs, and develops service plans to ensure a whole-person approach to care. This role collaborates with internal and external programs to empower clients with the knowledge and skills to self-manage their HIV care and other healthcare needs. Cultural competency is essential to serve the unique needs of the 2LGBTQIA+ community, communities of color, and other marginalized or vulnerable populations affected by HIV.

Responsibilities

• Conduct comprehensive psychosocial and program/service eligibility assessments and reassessments for case management clients, ensuring timely and coordinated access to medically appropriate health and supportive services, as well as continuity of care for those living with HIV, per the Ryan White Program guidelines in Maricopa County, Arizona.
• Curate and complete individualized service plans with clients to set goals and strategies for overcoming barriers to maintaining medical care, including mental health, chemical health, housing stability, or criminal history. Monitor and re-evaluate plans every six months, adapting as necessary, with the primary goal of enabling clients to self-manage their care.
• Close gaps in medical care by providing guidance and support that empowers clients to attend medical and wellness visits, ensuring access, follow-up, and adherence to treatments and supportive services that enhance harm reduction, behavior change, and maintenance.
• Manage an active caseload of clients, classified as either medical or non-medical level of care, ensuring at least 60% of time spent is billable to the Ryan White Program.
• Demonstrate culturally appropriate and reactive engagements with all individuals in the community, documenting records, referrals, and communicating with clients via telephone, email, and in-person.
• Provide clear, accurate, and current information to clients, community members, and volunteers, including prevention and harm reduction information, using a status-neutral approach with respect, empathy, and patience.
• Record all contacts and activities in system databases and EMR within 24 hours of encounter, completing and submitting all relevant documentation within 72 hours, in accordance with state policy.
• Submit billable units from the previous calendar month into the appropriate state database by the third day of every month.
• Provide information and referrals to partnering agencies for additional support and services, including social and medical needs not met by Prisma.
• Eliminate barriers to care through insurance navigation, including assisting patients with enrolling in State Medicaid (AHCCCS) and qualifying patient assistance programs.
• Stay informed and engaged with emerging research, trends, and best practices in sexual health, gender identity, intersectionality, and overall wellbeing.
• Collaborate with other teams to develop and evolve departmental and organizational needs, including policy reformation, cross-training, and identifying opportunities for growth and improvement.
• Work directly with department leadership on other program-related tasks.

Requirements

• Bachelor’s degree in social work or a comparable health or human services field, or a minimum of four (4) years of case management or related field experience with a high school diploma or equivalent.
• Demonstrated ability to establish rapport and maintain effective communication with culturally diverse populations from a wide range of life circumstances and backgrounds.
• Knowledge of issues and community resources related to HIV, chemical dependency, mental health, housing, health insurance, and other barriers to care.
• Sound understanding of gender identity, gender expression, sex, sexual orientation, and local/national resources for transgender or gender non-conforming individuals.
• Proficiency in Microsoft Office (Teams, Word, Excel, Outlook, PowerPoint) and competence in using electronic medical records and information systems, with a full understanding of HIPAA and patient confidentiality.
• Understanding of basic medical terminology.
• Highly organized self-starter with excellent problem-solving skills, ability to multi-task, and willingness to learn.
• Ability to work in a fast-paced environment with changing deadlines and priorities while maintaining a positive attitude and managing stress proactively.
• Excellent written and verbal communication skills, exemplifying professionalism, flexibility, and compassion, with the ability to de-escalate tense situations.
• Ability to work effectively in a mission-driven organization with diverse clients and staff in terms of race, ethnicity, sex, gender identity, sexual orientation, socio-economic status, nationality, and religion.

Preferred Qualifications

• At least one (1) year of direct experience working with individuals impacted by HIV.
• Valid driver’s license, insurable driving record, and access to a reliable personal vehicle for work-related activities.
• Bilingual in Spanish and English (speaking and listening skills).
• Experience with eClinical Works (eCW), Ryan White (RW), and CAREWare.

Environmental Factors and Physical Requirements

• Work primarily in a climate-controlled office environment with minimal safety/health hazard potential.
• Travel outside of the Phoenix area approximately 10% of the time.
• Exposure to computer screens for lengthy periods of time.
• Non-exempt position that may require evening and occasional weekend work.
• Regularly required to walk, sit, stand, use hands, talk, and hear; occasionally required to reach with hands and arms and lift objects up to 20 pounds.
• Specific vision abilities required include close vision, distance vision, and ability to adjust focus.

Compliance Requirements

• Currently have, or be able to obtain within 90 days of employment, a valid Fingerprint Clearance Card.
• Currently have, or are able to obtain within 30 days of employment, a clear TB test.
• Currently have, or are able to obtain within 30 days of employment, a current flu vaccination.
• Currently have, or are able to initiate within 30 days of employment, a Hepatitis-B primary vaccination series.
• Currently have, or are able to obtain within 30 days of employment, a CPR certification.