Outreach Case Manager

Who we are: Since 1985, BHCHP’s mission has been to ensure unconditionally equitable and dignified access to the highest quality health care for all individuals and families experiencing homelessness in greater Boston. Over 10,000 homeless individuals are cared for by Boston Health Care for the Homeless Program each year. We are committed to ensuring that every one of these individuals has access to comprehensive health care, from preventative dental care to cancer treatment. Our clinicians, case managers, and behavioral health professionals work in more than 30 locations to serve some of our community’s most vulnerable—and most resilient—citizens. From our earliest days as a program, we have always sought to do work that is transformational: recognizing our shared humanity; centering dignity, compassion, mutual respect and supporting the right of every individual to access the highest levels of health care and every staff member to reach their fullest potential. We continue to be committed to building bridges and breaking down barriers, including systemic racism which harms us all. We provide community-based health care services that are compassionate, dignified, and culturally appropriate, incorporating social determinants of health, with the goal of breaking down the physical and systemic barriers that our patients face. Job Summary: Hours: Full-time; Monday – Friday, 8:30am – 5:00pm Union: Yes Union Name: 1199 SEIU Patient Facing: Yes The Outreach Case Manager (OCM) is part of a nationally recognized, innovative multidisciplinary HIV Primary Care Team at Boston Health Care for the Homeless Program (BHCHP). The OCM provides community-based outreach, linkage, and retention services to support patients in engaging and remaining in HIV primary care. Working alongside Outreach Nurses and an Outreach Social Worker, the OCM identifies and engages a vulnerable subset of patients who would benefit from enhanced outreach-based support. The Outreach Team helps patients overcome barriers to care, including homelessness and housing instability, substance use disorder, legal system involvement, and challenges accessing insurance and other public benefits. Using a patient-centered, strengths-based approach, the OCM works intensively with patients for up to one year to promote sustained engagement in HIV primary care at BHCHP and support their transition to greater independence in managing their care. This position has been funded by the Massachusetts Department of Public Health for more than 10 years and is currently funded through June 30, 2028, with the possibility of renewal. If funding is not renewed, the position will end on June 30, 2028. Responsibilities: Provide intensive linkage and retention outreach services to approximately 20 of the HIV team’s most vulnerable patients living with HIV and experiencing homelessness or housing instability, with a focus on building therapeutic relationships to promote medication adherence and active engagement in health care. Linkage and retention services specifically will include: Accompaniment to medical, social service, housing and legal appointments and debriefing with patients after visits and updating HIV team and collaborating agencies as needed Active follow-up on client referrals to a wide range of support services Field-based outreach and other activities to locate patients who may be out of care, or at high risk of disengaging from care. Outreach may be conducted with other team members including HIV nurses, providers, behavioral health providers, and case managers. Outreach sites may include streets, shelters, patient homes, AIDS service organizations, hospitals, residential treatment programs, and other locales as needed. (Outreach is always done with at least one other outreach staff member) Co-create Individual Service Plans with clients as well as with input of the multidisciplinary HIV team, monitor implementation of plans and document updates in electronic medical record Ensure linkage to emergency psychiatric services, when necessary, in partnership with behavioral health team Assist with care coordination during discharge planning for patients in an inpatient setting at local hospitals Provide advocacy for patients involved in the criminal legal system, assist patients in reconnecting to care in the post-release period Provide motivational interviewing and risk reduction counseling for patients with substance use disorders, as well as for those engaging in other high-risk behaviors Work with team to identify potential candidates for linkage and retention intervention; as well as to identify patients who are ready to transition from the intensive outreach to more clinic-based traditional case management services Document all client interventions/activities and referrals in electronic medical record Complete all reporting duties as required by grant agencies, and other reports as requested Fulfill all mandatory reporting duties as required by MA regulating agencies Participate in weekly multidisciplinary Patient Care Meetings and monthly HIV Team meetings as well as attend Team Huddles as appropriate Successfully complete the MassHealth Certified Application Counselor exam (CAC) within 60 days of hire and maintain active certification status. Provide documentation for grants, projects, etc. as directed by the Supervisor Participate in intra-agency committees Qualifications: Experience and Education: Associate’s, or bachelor’s degree in a related field and/ or equivalent to two years’ relevant human services experience Experience and interest in working with people living with HIV and experiencing homelessness and housing instability Experience conducting outreach in non-clinic-based settings Basic Knowledge/Skills: Computer proficiency Strong organizational skills Strong interpersonal and communication skills Experience in behavioral de-escalation, desired Experience with electronic health records is desired Experience in trauma informed care, motivational interviewing, and risk reduction frameworks, desired Bilingual English-Spanish preferred Other Job Requirements Demonstrated interest in working with vulnerable populations including those with active substance use disorder and mental illness Interest and willingness to work in multidisciplinary team setting Commitment to equitable and culturally appropriate care for a wide range of diverse populations Compensation and Benefits: The compensation increases based on years of experience and ranges from $22.25 - $35.60 per hour. BHCHP full-time employees are eligible for our competitive time off program, health, dental and vision insurance, 403B retirement savings plan, pre-tax MBTA pass program with 40% discount, additional compensation for demonstrated bilingual proficiency and more. Benefits are prorated for part-time employees. Does this amazing opportunity interest you? Then we'd love to hear from you. As an equal opportunity employer, Boston Health Care for the Homeless Program is committed to providing employment opportunities to all qualified individuals and does not discriminate on the basis of race, color, ethnicity, religion, sex, gender, gender identity and expression, sexual orientation, national origin, disability, age, marital status, veteran status, pregnancy, parental status, genetic information or characteristics, or any other basis prohibited by applicable law. Covid-19 Vaccination: Proof of Covid-19 vaccination(s) is optional for employment. Candidates who are offered employment will be given details about how to demonstrate receipt of vaccination if they choose to. Please Note: Employment at Boston Health Care for the Homeless is at-will. Boston Health Care for the Homeless does not sponsor work authorization visas.