Retention in Care Case Manager
Job Details
Broadway - Kansas City, MO

This position will work within the Connections to Care (C2C) project. The focus of this project is to re-engage clients who are considered lost to HIV medical care and have not had an HIV medical appointment in six months or greater. This position will have a unique role in the identification and engagement of this population and will provide targeted outreach to this group of clients in order to help them re-engage in their HIV Medical care

Essential Functions:

Client Assessment, Service Planning, Care Coordination, and Customer Service

  • Partners with KC CARE Health Center Prevention staff, Peer Program, the Linkage to Care team, and the Surveillance Department at the Kansas City Health Department to identify and engage clients who have previously been lost to HIV medical care;
  • Partners with the KC CARE Health Center Peer Program and the Surveillance Department at the Kansas City Health Department to locate clients in the community once identified as having fallen out of HIV medical care. This would include and is not limited to: phone contact, letters, home visits, and outreach into the community;
  • As needed, partners with Medical Case Managers at the KC CARE Health Center to help consult/re-engage clients who are at risk of falling out of HIV Medical Care. Partners with Linkage to Care team to assist with clients on their caseloads who are not responding to attempts at outreach;
  • Compiles comprehensive client assessments in order to develop and asses the efficacy of an HIV-focused plan of care (goal/service plan), specifically targeting reasons that clients previously fell out of HIV medical care;
  • Evaluates the client’s eligibility for government funded programs (i.e. Medicaid, Medicare, Social Security etc.), and provides referrals and follow up as appropriate;
  • Participates in client progress review, community placement, follow-up services, and discharge planning by participating on the health center’s HIV Multidisciplinary Team and/or with other community based organizations or medical providers as necessary;
  • Provides ongoing client referrals to appropriate community resources and services based on client need and eligibility. Confers with said referrals (medical facilities, schools, community groups, public health, social service agencies, and other service providers) to discuss client referrals, follow-up care, decisions affecting the client, and to explain agency policies, treatment philosophy, and programs; when sharing client information, maintain HIPAA and client confidentiality standards;
  • Maintains regular contact with clients to provide ongoing assessment, support, intervention and satisfaction of services. Will work with clients for a minimum of 6 months and will transfer on or after a client’s 6-month update. As this is a short-term intensive case management program, contact will be made weekly for the first 12 weeks of engagement in Linkage to Care. Contact will then gradually disengage to every other week for the duration of the Linkage to Care Program. This includes timely follow-up with client plan of care (goal/service plan) as documented in client file (SCOUT Service Plan);

Client Education, Access to Health Coverage, and Advocacy

  • Provides education to clients on HIV, medication and medical appointment adherence, viral load and CD4 lab results, and risk reduction strategies; provides specific education to clients regarding: coping and acceptance of HIV diagnosis, navigation of health care system, and HIV education
  • Enrolls/makes referrals for clients to enroll in the most comprehensive insurance plan available to them (Medicaid, Medicare, Marketplace Plan, Off-Marketplace plan, COBRA, etc); assesses client eligibility for insurance premium and co-pay assistance; educates clients on process for submitting insurance and co-pay documentation; and works closely with client and necessary third-parties (including insurance companies) to maintain insurance coverage;
  • Serves as client advocate to ensure access to, and understanding of, needed services; this may include assisting clients in applying for government funded programs, connecting clients to legal resources, serving as client reference for service applications; and attending medical appointments routinely to ensure client understanding of medical care and treatment regimen
  • Identify and collaborate with community partners that might be able to provide needed services to clients to help them reconnect into medical care, such as housing agencies and community support agencies; maintain a 


Data and Quality Management

  • Maintains professional, well written, comprehensive, and accurate client record, documenting interactions with clients and/or on behalf of clients and according to program standards (SCOUT database);
  • Completes program reports and data requests in an accurate, thorough, timely manner (including, but not limited to, monthly program reports, and data requests from regional and state levels)
  • Participates in quality improvement projects as requested, including researching client data/trends, utilizing data measures to prioritize client contact, and assisting in streamlining internal procedures 

HIV Case Management Team Support; and Clinic and Community Involvement

  • After intakes for clients who have not had a medical appointment in over 6 months, will assess a client’s appropriateness for the Linkage to Care Program versus standard HIV Case Management
  • Attends scheduled Kansas City Health Department Ryan White Title I/Title II HIV Case Management meetings and other internal team meetings as scheduled by the program supervisor; and attends Comprehensive HIV Prevention and Care Planning Council monthly meetings on a rotating team schedule
  • Participates in community outreach events including counseling and testing, overview of Linkage to Care Program, and educational needs as requested. Events may include evening and weekend hours.
  • Supports the mission and vision of the KC CARE Health Center;  
  • Operates as a team member of the KC CARE Health Center; supporting other staff members when needed; 
  • All duties as assigned by Department Director or Senior Staff Members when required for the smooth operation of KC CARE Health Center and/or its Administrative functions. Perform other duties as assigned that are related to HIV continuum of care programming;



Minimum Requirements for Retention in Care Case Manager I:

  • Bachelor’s degree in Social Work, R.N., B.S.N., or 2 years’ experience in Case Management type services; less than 3 years’ post graduate experience in Case Management type services or
  • Master’s degree in Social Work, Nursing, or related field, with less than 2 years’ post graduate experience
  • HIV/AIDS, hepatitis, and substance abuse prevention or service coordination experience with the target population preferred;
  • Demonstrated experience serving a diverse population;
  • Possess clinical problem solving and critical thinking skills.

Minimum Requirements for Retention in Care Case Manager II:

  • Two years’ experience as a Case Manager I or
  • Bachelor’s degree in Social Work, R.N., B.S.N., or 2 years’ experience in Case Management type services; at least 3 years’ post graduate experience of which at least 2 years’ experience in HIV Case Management or
  • Master’s degree in Social Work, Nursing, or related field, with at least 2 years’ post graduate experience of which at least one year is in HIV Case Management
  • Active participation in at least one Clinic committee or Ryan White Planning Council Subcommittee
  • Participation in an ongoing quality improvement project/special project
  • Obtains and maintains state-issued rapid HIV/HCV testing method certification for provision of counseling, testing and referral (CTR) services.

Physical Demands/Working Conditions:

  • Intermittent physical activity including walking, standing, sitting, stooping, lifting boxes and files under 25 pounds and lifting.
  • Potential exposure to virus, disease and infection from patients in working environment.
  • May be required to work extended periods based on business need.

The above information is intended to describe the most important aspects of the job.  This job description is not intended to be construed as an exhaustive list of all responsibilities, duties and skills required in order to perform the work. Duties, responsibilities and activities may change at any time with or without notice. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job. The Kansas City CARE Clinic is committed to providing equal employment opportunity/affirmative action (EEO/AA) to all job applicants and employees.