Case Manager, Ryan White Part B/C and Retention Coordinator

Description

POSITION SUMMARY 

The RW Part B/C Medical Case Manager is responsible for providing comprehensive medical case management services under both Ryan White Part B and Part C programs while leading patient retention and engagement efforts within the HIV program. 

This position ensures clients receive coordinated medical care, support services, and eligibility determination in accordance with program requirements. Additionally, the Retention Coordinator component focuses on reducing gaps in care, improving appointment adherence, and supporting viral suppression outcomes through targeted outreach, tracking, and re-engagement strategies. 

This role requires strong knowledge of Ryan White Part B and Part C program requirements, eligibility processes, and data systems, along with the ability to collaborate across interdisciplinary teams to ensure high-quality, compliant, and patient-centered care.
 

REPORTING RELATIONSHIPS

This position reports to the RW Grants Administrator. This position does not supervise any other position.

ESSENTIAL JOB DUTIES AND FUNCTIONS

 While living and demonstrating our Core Values, the RW Part B/C Medical Case Manager and Retention Coordinator will:

• Conduct comprehensive assessments of clients’ medical, psychosocial, financial, and support service needs.
• Complete intake assessments, reassessments, recertifications, acuity scales, budgets, and all required case management documentation.
• Develop and implement individualized service coordination plans based on client needs.
• Coordinate access to medical care, including antiretroviral therapy and supportive services.
• Support medication adherence and provide education on treatment importance.
• Assist clients in navigating healthcare systems, insurance, and community resources.
• Advocate for clients to ensure access to appropriate medical care and support services.
• Determine and document eligibility for Ryan White Part B and Part C programs, including proof of income, residency, insurance, and identification.
• Complete eligibility recertifications in accordance with program requirements.
• Ensure all required eligibility documentation is current, accurate, and maintained in the electronic medical record.
• Assist clients with sliding fee discount applications and financial assistance programs.
• Maintain compliance with all Ryan White data reporting and documentation standards.
• Monitor and track patients who are out of care, at risk of falling out of care, or non-adherent to treatment.
• Conduct outreach to re-engage patients who have missed appointments, labs, or follow-up care.
• Work to reduce gaps in care and improve retention and viral suppression rates.
• Collaborate with providers and care teams to develop strategies for patient engagement and retention.
• Maintain and regularly update retention tracking tools, reports, and patient lists.
• Identify trends and barriers to care and participate in quality improvement initiatives to address them.
• Collaborate with healthcare providers, social service agencies, and community organizations.
• Participate in interdisciplinary team (IDT) meetings, case management huddles, and compliance meetings.
• Maintain a current list of referral resources available to clients.
• Maintain accurate and timely documentation in CAREWare and the Electronic Medical Record.
• Enter all case notes within five business days or by the third business day of the following month, whichever comes first.
• Ensure all services are entered accurately to support reporting and invoicing processes.
• Attend trainings, conferences, and meetings to maintain clinical and public health knowledge.
• Demonstrate cultural competence and sensitivity when working with diverse populations.
• Demonstrate flexibility and professionalism in a dynamic healthcare environment.
• Participate in quality management and program improvement initiatives.
• Perform other duties as assigned.

Requirements

• Meet The Wright Center for Community Health and its affiliated entity The Wright Center for Graduate Medical Education EOS© People Analyzer Tool
• Buy in and experience working in the EOS® model (strongly preferred)
• Mission-oriented; represents the enterprise in a professional manner while demonstrating organizational pride
• Bachelor’s degree in social work, psychology, sociology, or a related field preferred; will accept a combination of relevant education and experience with a minimum of four (4) years in a related field in lieu of a degree
• Knowledge of HIV preferred
• Basic Life Support (BLS) certification required
• Excellent verbal and written communication skills 
• Demonstrated cultural competence and sensitivity in working with diverse populations, recognizing and respecting individual differences and unique needs, especially in the context of HIV/AIDS.
• Ability to advocate on behalf of clients to ensure they receive appropriate medical care, social services, and support. 
• Strong organizational and documentation skills
• Ability to work collaboratively with healthcare professionals, social service agencies, and community organizations to ensure a coordinated and holistic approach to client care.
• Flexibility and adaptability to respond to the evolving needs of clients and the healthcare environment.
• Commitment to maintaining client confidentiality and upholding ethical standards in all interactions and interventions.