Ryan White Non-Medical Case Manager

Who We Are:

Native American Community Clinic opened its doors in 2003 to address the health disparities within the urban Native American community of the Twin Cities. Our mission is to promote the health & wellness of mind, body, and spirit of Native American families. We offer a full range of healthcare services that include Medical, Behavioral Health, Dental, and Substance Abuse programs. NACC offers comprehensive HIV services, including robust HIV testing programs, partner services, HIV care and other infectious disease care, and HIV prevention services, including PrEP/PEP.

NACC also offers full-spectrum harm reduction services, both within the clinic setting and in outreach settings. NACC approaches healthcare by addressing root causes of health disparities including access to food, housing and health insurance with services such as resource navigation, care coordination, outreach and community-based activities through the use of our peer recovery coaches and community health workers. NACC strives to honor health and tradition by providing spiritual care and access to traditional healing through our Elders in Residence.

The Ryan White Non-Medical Case Manager (NMCM) provides supportive case management services to individuals living with HIV, focusing on improving access to and retention in needed core medical and other support services. In the context of an integrated collaborative team, this position independently carries a caseload of clients, leads the delivery of social services and benefits navigation, and is responsible for ongoing documentation and data reporting to funders.

The NMCM provides coordination, guidance, and assistance in accessing medical, social, community, legal, financial, employment, vocational, and/or other needed services. Services are delivered within a harm-reduction model, utilizing a nonjudgmental approach to clients’ substance use and other factors. This position offers an opportunity to make a significant impact in the lives of individuals living with HIV, contributing to the efficiency and effectiveness of their care and support systems.

Provide the following services to clients:

• Conduct initial assessments for eligibility determination and service needs identification.
• Develop individualized care plans that respect the client's cultural values, addressing barriers to care including homelessness or injection drug use, in a nonjudgmental manner.
• Continuous client monitoring to assess the efficacy of the care plan
• Re-evaluation of the care plan at least every 6 months with adaptations as necessary
• Provide education and guidance to clients about HIV care and treatment options, ensuring timely and coordinated access to medically appropriate levels of health and support services and continuity of care
• Assist clients in navigating benefits and healthcare systems.
• Assist clients in accessing available resources, such as food access, social supports, housing resources, and specialty healthcare.
• Support clients in transportation needs, and accompany patients to appointments as appropriate.
• Advocate for clients and review their utilization of services, ensuring they are client-specific.
• Ongoing assessment of the client’s and other key family members’ needs and personal support systems
• Consistently and efficiently tracking and reporting Ryan White required data
• Work in coordination with another Ryan White Medical and Non-Medical Case managers
• Work collaboratively with an interdisciplinary team, including directly with the HIV clinical care team.
• Ensure a high level of confidentiality and sensitivity while dealing with clients' personal information.
• Engage with clients using various methods (phone, in-person, outreach, during clinic visits) including harm reduction-based community outreach.
• Maintain ongoing documentation in compliance with Ryan White program requirements.

This job has no supervisory responsibilities.

• Case management experience, including self-directed follow-up with clients in a timely manner
• Direct experience working with American Indian/Alaska Native communities
• Ability to deliver…