Ryan White Case Manager

Position Title: Ryan White/EHE Medical Case Manager
Reports To: Program Coordinator
FLSA Status: Non-Exempt
Location: Miami Shores/Coral Springs, FL, 33071
Job Type: Full-Time

Position Summary

The Ryan White & EHE Initiatives Case Manager provides comprehensive, client-centered case management services to people living with HIV (PLWH) and individuals at risk, integrating the core medical service requirements of HRSA’s PCN 16-02 with the targeted strategies of the Ending the HIV Epidemic (EHE) initiatives. This position facilitates rapid linkage to care, retention in care, treatment adherence, and access to prevention and support services to improve health outcomes and reduce HIV transmission.

Essential Duties and Responsibilities

1. Initial Client Engagement & Assessment

• Conduct comprehensive biopsychosocial assessments for PLWH and high-risk individuals identified through outreach, testing, or referrals.
• Assess medical, behavioral health, psychosocial, housing, and prevention needs.
• Verify eligibility for Ryan White services and document per program guidelines.

2. Service Plan Development

• Develop individualized care plans with measurable health outcomes, incorporating treatment adherence, prevention strategies, and EHE rapid-start protocols.
• Collaborate with medical providers, prevention staff, and other support service providers to ensure holistic care.

3. Care Coordination & Navigation

• Link clients to primary medical care, ART initiation, PrEP services, behavioral health, oral health, and other core medical services.
• Coordinate referrals for housing, food, transportation, legal assistance, and benefits enrollment.
• Ensure rapid linkage to care (ideally within 7 days of diagnosis or re-engagement need).

4. Ongoing Monitoring & Follow-Up

• Maintain regular client contact (minimum every six months for Ryan White clients; more frequent for EHE outreach clients).
• Track care plan progress, viral load suppression, and PrEP adherence.
• Address emerging barriers to care promptly.

5. Treatment Adherence & Prevention Counseling

• Provide education on HIV disease management, ART adherence, PrEP, and U=U (Undetectable = Untransmittable) messaging.
• Support clients in reducing risk behaviors and improving overall health.

6. Outreach & Re-Engagement (EHE Focus)

• Conduct targeted outreach to locate and re-engage individuals out of care.
• Partner with community organizations to reach high-incidence and underserved populations.
• Participate in mobile testing and community events as needed.

7. Documentation & Compliance

• Maintain timely, accurate case notes and service records in the agency’s electronic case management system in compliance with Ryan White and EHE reporting requirements.
• Ensure all services meet HRSA PCN 16-02 definitions for Medical Case Management.
• Track and report EHE performance measures (linkage to care, viral suppression, PrEP initiation, re-engagement rates).

Minimum Qualifications

• Master’s degree in social work, Nursing, Public Health, Human Services, or related field
• Minimum of two (2) years’ experience in HIV case management, prevention, or outreach.
• Knowledge of the HIV care continuum, Ryan White Program requirements, and EHE strategies.
• Familiarity with community resources, prevention interventions, and culturally competent care practices.
• Strong interpersonal, organizational, and communication skills.
• Computer proficiency and experience with electronic case management systems.
• Valid driver’s license and reliable transportation; ability to conduct home, community, and clinic visits.
• Bilingual (English/Spanish or English/Creole) strongly preferred.

Work Environment

• Combination of offices, clinics, and community settings.
• May require evening or weekend hours to meet client needs.
• Frequent travel within the service area.

Benefits

• 401(k) with employer matching
• Flexible schedule
• Health insurance

Job Type: Full-time

Pay: $45,000.00 - $50,000.00 per year

Benefits:

• 401(k)
• Flexible schedule
• Health insurance
• Health savings account
• Paid time off

Education:

• Bachelor's (Preferred)

Experience:

• Case Management: 1 year (Preferred)

License/Certification:

• Driver's License (Preferred)

Work Location: In person

Salary : $45,000 - $50,000