Manager Ryan White Case Management

Benefits

• Paid Time Off & Paid Company Holidays
• Medical, Dental, Vision & Life Insurance
• Flexible Spending Account (FSA)
• 403(b) Retirement Plan with Company Match
• Short-Term & Long-Term Disability
• $0 Copay for Legacy Provider visits
• $0 Copay for prescriptions filled at Legacy Pharmacies
• Travel Insurance & Pet Insurance
• Subsidized Gym Membership
• And much more!

Apply today in less than 3 minutes using your phone, tablet, or computer!

Location: Legacy Montrose Allen Parkway - 2929 Allen Pkwy. Houston, TX 77019

Manager - Ryan White Case Management - LMSW (Job Overview)

Schedule: Monday-Friday (8AM-5PM) | Hybrid

As a Ryan White Case Manager, you’ll build meaningful relationships with people living with HIV and help connect them with the care, resources, and support they need to thrive. Referred by Legacy providers, patients will count on your compassion, advocacy, and expertise as you help address medical, psychosocial, and everyday living needs.

This grant-funded position gives you the opportunity to make a lasting difference within the community healthcare ecosystem. Working alongside patients, families, providers, and community partners, you’ll help reduce barriers, strengthen continuity of care, and support improved health outcomes.

How You’ll Make a Difference

• Provide comprehensive psychosocial services, including case management, linkages to care, patient advocacy, medication and visit adherence support, and psychological and social support.
• Help patients understand and navigate Ryan White Part-A eligibility, medical coverage, coverage caps, and available services.
• Support patients as they return to care, access essential resources, and build greater independence in managing their health.
• Work within a collaborative primary care medical home that values a team-based, whole-person approach.
• Partner with patients and families to promote culturally sensitive, language-appropriate, timely, and continuous care.

A Collaborative and Meaningful Role

• Join a team committed to respectful, professional, and courteous relationships with patients, families, visitors, and colleagues.
• Collaborate with healthcare professionals, peers, supervisors, and community resources to address service gaps and improve patient outcomes.
• Participate in trainings, community meetings, performance improvement, and quality assurance efforts that support your continued growth and development.
• Make a meaningful impact by helping people living with HIV access care, overcome obstacles, and develop appropriate self-management skills.

Key Responsibilities

• Identify and screen HIV+ individuals who have been referred for social service needs by Legacy providers.
• Assist clients with obtaining and securing required documentation for program eligibility, including Social Security documentation, tax documents, verification of income, and proof of residency.
• Assist patients with drug assistance program eligibility application completion, including obtaining and securing required documentation.
• Enter all data into the Harris County Ryan White Centralized Patient Care Data Management System (CPCDMS) to register new patients.
• Facilitate the transfer of CPCDMS record ownership for patients transferring care from another Ryan White funded primary care agency to Legacy Community Health.
• Ensure patients are educated on services covered under Ryan White Part-A, coverage caps, and RW medical coverage.
• Coordinate the collection and housing of Ryan White CPCDMS eligibility supportive documentation.
• Assist with the preparation and implementation of the CPCDMS Eligibility portion of the Annual Ryan White Part-A Audit, as needed.
• Assess each client’s medical and psychosocial history and current service needs, including resources to meet daily living needs.
• Provide information, referrals, and assistance with linkage to medical, psychosocial, and basic needs services to improve patients’ independence and overall health.
• Assist patients with improved medication adherence, visit adherence, and overall health status.
• Assess for substance use/abuse and connect patients to available treatment resources.
• Advocate on behalf of clients to decrease service gaps and remove barriers to services.
• Assist patients who have been lost to care with returning to medical services.
• Comply with standards of care, including DSHS Texas HIV Management Standards and other applicable standards of care.
• Follow program standards and protocols, including completing Comprehensive Assessments and Individualized Care Plans with patients.
• Maintain paperwork and documentation necessary for program standards.
• Attend trainings and community meetings as needed.
• Monitor the efficacy and quality of services through periodic re-evaluation with peers and supervisor.
• Document services provided in the EHRS client record within 72 hours.
• Participate in Legacy’s Performance Improvement and Quality Assurance Program.
• Demonstrate respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.
• Promote effective working relationships and work effectively as part of a team to facilitate the department’s ability to meet its goals and objectives.
• Attend required training and ongoing education offered by the agency, including but not limited to safety trainings and education sessions on Universal Precautions.
• Maintain the work area and equipment in the condition required by Legacy standards.
• Work within the context of a primary care medical home, applying a team-based approach to care while working in partnership with patients and families to promote timely access to care, culturally sensitive and language-appropriate care, continuity of care, and whole-person improvement through appropriate self-management skills.
• Perform other duties as assigned.

Minimum Qualifications

• Master’s degree in social work is required.
• Current Texas Licensed Master of Social Work (LMSW) is required. All licensed professionals must maintain their professional licenses as defined by their respective Texas licensing/examining boards.

Required Years of Experience

• One year of case management experience with people living with HIV and/or persons with a history of mental illness, homelessness, or chemical dependence is required.

Required Knowledge, Skills, and/or Abilities

• Must be able to travel between locations as needed, including the ability to travel between Houston and Beaumont.
• Requires a working knowledge of community issues and Treatment issues related to HIV.
• Must be able to manage multiple deadlines and decision-making responsibilities.
• Demonstrated competency with an EHRS system
• Excellent communication skills and customer service skills.
• Ability to multitask in a fast-paced environment.
• Bilingual / Spanish fluency.
• Above average organizational skills.
• Strong typing and computer skills.
• This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management

Desirable Knowledge, Skills, and/or Abilities

• Bilingual (English/Spanish) is preferred. If the employee is bilingual, then they must have written and verbal fluency in English and Spanish.
• Experience working among the gay, lesbian, bisexual and transgender community is preferred.

About Legacy Community Health

The largest Federally Qualified Health Center (FQHC) in Southeast Texas, Legacy Community Health has delivered affordable, high-quality care for nearly 40 years across 50+ clinics in Greater Houston and the Gulf Coast. Our mission — driving healthy change in our communities — guides everything we do, and it starts with our people.

Approachable & Collaborative — Leads with humility, values diverse perspectives, and builds trust through teamwork.

Driven & Committed — Takes initiative and goes the extra mile to improve patient outcomes and drive continuous improvement.

Thoughtful Communicators — Pairs clinical/technical skill with emotional intelligence, navigating complex situations with empathy and professionalism.