Ryan White Case Manager

The Ryan White Case Manager position provides various levels of case management assistance to those living with HIV, many of whom seek help with understanding and learning about their diagnosis, medication adherence, mental illness, housing instability, food insecurity, and other barriers that challenge their ability to maintain care and viral suppression. As an advocate for the client, the Case Manager will perform assessments for clients entering the Ryan White Case Management Program at Prisma Community Care, identifying client-specific needs and developing service plans to ensure a whole-person approach to care. This role will work heavily with internal and external programs and resources to ensure clients are empowered with the knowledge and skills to self-manage their HIV care and other healthcare needs after working with their Case Manager. This role demands a high level of cultural competency to serve the unique needs of the 2LGBTQIA+ community, communities of color, and other marginalized and/or vulnerable populations, with specific consideration for those living with and impacted by HIV.

Essential Functions

Responsibilities include, but are not limited to:

• Conduct comprehensive psychosocial and program / service eligibility assessments and reassessments of case management clients, showcasing timely and coordinated access to medically appropriate levels of health and supportive services, as well as continuity of care for those living with HIV, as indicated by the Ryan White Program managed within Maricopa County, Arizona.
• Curate and complete individualized service plans with clients to set goals and strategies to overcome barriers to maintaining medical care, which could include but is not limited to mental health, chemical health, housing stability, or criminal history. Service plans will include continuous client monitoring to assess the efficacy of the care plan, with re-evaluation every six months and adaptations as necessary, and the primary objective to become self-managed in their care by the end of the working relationship.
• Close gaps in medical care through effective guidance and support that empowers clients to attend medical and wellness visits, ensuring access, follow-up, and adherence to treatments and other requirements, including supportive services that can enhance harm reduction, behavior change, and maintenance.
• Manage an active caseload of clients enrolled in case management services at Prisma Community Care, classified as either medical or non-medical level of care, ensuring a collective productivity level of at least 60% of time spent is billable to the Ryan White Program between both groups of clients.
• Demonstrate culturally appropriate and culturally reactive engagements with all individuals within the community, performing services, documenting records and referrals, as well as communicating with clients via telephone, email, and in-person.
• Provide clear, understandable, current, and accurate information to clients, community members, and volunteers. Provide prevention and harm reduction information in a way that shows respect, listening skills, empathy, and patience in a status-neutral approach.
• Record all contacts and activities into all system databases and EMR within 24 hours of encounter, completing and submitting all relevant information in accordance with state policy, including documentation into appropriate databases and reporting systems, and finalizing all documentation within 72 hours of actions being completed.
• Submit billable units from each previous calendar month into the appropriate state database by the third day of every month.
• Provide information and referrals for other partnering agencies that provide additional support and services to include social and medical needs that cannot be met by Prisma.
• Eliminate barriers to care through insurance navigation and enrolling patients in qualifying patient assistance programs that increase access to care. Insurance navigation includes assisting patients in the processes of enrolling in State Medicaid (AHCCCS).
• Stay informed, engaged, and current with emerging research, trends, and best practices in the field of sexual health and wellness, gender identity, intersectionality, and wellbeing of all.
• Work collaboratively with other teams to further develop and evolve the needs of the department and organization, including but not limited to, policy reformation, cross-training, and identifying opportunities for growth and improvement within teams.
• Work directly with the department leadership with other program-related tasks.