Case Manager - Tu Bienestar

Casa Esperanza, Inc. is a bilingual/bicultural behavioral health treatment provider serving Boston and the Merrimack Valley. Our mission is to empower individuals and families to recover from addiction, trauma, mental illness, and other chronic medical conditions; overcome homelessness and discrimination; and achieve health and wellness through comprehensive, integrated care.

The role of the Tu Bienestar Case Manager is to ensure clients are linked to care, engaged in care, and achieve and maintain viral suppression. They will facilitate access to and coordination of needed services for HIV+ clients, including medical and dental care, prescription services, medical treatment compliance, enrollment in the Massachusetts HIV Drug Assistance Program, mental health/substance abuse counseling, and social services.

This individual will also conduct needs assessments, develop service plans, and complete other related paperwork. The Case Manager will conduct file reviews and track the utilization of services to ensure that benchmarks, timelines, goals, and objectives are being met. They will be responsible for all required reporting and attending any relevant conferences and meetings. As part of the Casa Esperanza, Inc.

team, you will provide services in a fully integrated, holistic, and collaborative manner using a team-treatment approach to ensure the coordination of all client services, both across Casa programs and with external providers. This integrated model aims to facilitate clear communication amongst all providers and eliminate duplication of efforts or conflicting approaches to care; detail necessary follow‑up and assignments; and ensure wrap‑around support services are in place to maximize treatment effectiveness and clinical outcomes.

• Coordinate admissions and intakes for Ryan White clients, including liaising with internal and external programs
• Ensure all clients meet eligibility for Part A services and document eligibility in the client record
• Conduct initial assessments and reassessments for each client and generate individualized service plans that reflect each client’s unique strengths, needs, abilities, and preferences, as appropriate
• Conduct periodic reassessments of the ISP, including review of the utilization of services and client‑specific advocacy
• Assist clients in choosing a primary care provider, making their first appointment, and obtaining health insurance
• Communicate directly with medical personnel to educate them about the client’s substance abuse issues, address any concerns, and work collaboratively to meet the client’s needs
• Coordinate access to medically appropriate levels of health care, behavioral health services, and other support services to ensure continuity of care
• Provide onboarding and annual training for all staff regarding the fundamentals of HIV/AIDS, HIV medications, and strategies for personal risk reduction
• Follow up and attend the EHE (Ending HIV Epidemic) request and follow up with the RW Team
• Attend and participate actively in the monthly meeting with the Boston Public Health Commission (BPHC) as needed
  • Participate and coordinate any Quality Improvement (QI) project for the RW program
• Bilingual Wellness Group and Client Education
• Help clients navigate entitlement and ancillary service systems to obtain necessary benefits, such as SSI, transportation, health insurance, and dental care
• Coordinate internal referrals to on‑site services, including GED/ESL education, peer support groups, mental health counseling, and vocational opportunities
• Coordinate client transportation as needed
• Follow‑up calls to maintain client engagement and re‑engagement
• Develop an aftercare plan with clients prior to discharge
• Provide general backup support for intakes at the Familias Unidas Outpatient Program
• Basic use of new work methods using appropriate technologies to provide telehealth services to clients as needed
• Other duties assigned related to case management‑related functions to support the program
• Collaborate with other agencies, public organizations, and external personnel
• Represent the agency by providing education and participating in…