Outreach Case Manager
Boston, MA
Full Time
HIV Team (ARCH)
Entry Level
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
In the context of a multidisciplinary HIV Primary Care team at Boston Healthcare for the Homeless Program (BHCHP) the Outreach Case Manager provides harm reduction oriented, community -based linkage and retention services to a subset of highly vulnerable homeless patients living with HIV/AIDS. Patients are referred to this specialized team if they are newly diagnosed with HIV, they are disengaged from care, or they are unable to manage adherence to HIV medications and do not have a fully suppressed HIV virus level. The Outreach Case Manager shares a patient panel with an Outreach Social worker and engages with patients to address barriers to care including substance use disorder, chronic homelessness, and legal issues. The Outreach Case Manager will work intensively with patients for up to 12 months to support them in successfully engaging in consistent and ongoing HIV primary care and medical case management at BHCHP. This position is funded until the end of June 2026 with the possibility for renewal. If this funding is not renewed, this position will end June 30, 2026.
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, with a focus on building therapeutic relationships to promote medication adherence and active engagement in health care.
Linkage and retention services specifically will include:
Experience and Education:
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
In the context of a multidisciplinary HIV Primary Care team at Boston Healthcare for the Homeless Program (BHCHP) the Outreach Case Manager provides harm reduction oriented, community -based linkage and retention services to a subset of highly vulnerable homeless patients living with HIV/AIDS. Patients are referred to this specialized team if they are newly diagnosed with HIV, they are disengaged from care, or they are unable to manage adherence to HIV medications and do not have a fully suppressed HIV virus level. The Outreach Case Manager shares a patient panel with an Outreach Social worker and engages with patients to address barriers to care including substance use disorder, chronic homelessness, and legal issues. The Outreach Case Manager will work intensively with patients for up to 12 months to support them in successfully engaging in consistent and ongoing HIV primary care and medical case management at BHCHP. This position is funded until the end of June 2026 with the possibility for renewal. If this funding is not renewed, this position will end June 30, 2026.
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, 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 (including residential treatment programs, housing, and food programs, etc.).
- 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, and medical case managers. Outreach sites will include streets, shelters, patient homes, AIDS service organizations, hospitals, residential treatment programs, and other locales as needed.
- Co-create Individual Service Plans (ISP) with clients as well as with input of the multidisciplinary HIV team, monitor implementation of ISP and document updates in electronic medical record.
- Ensure linkage to emergency psychiatric services when necessary; assist with care coordination during discharge planning for patients in an inpatient setting at local hospitals.
- Provide advocacy for patients involved in the criminal justice system, assist patients in reconnecting to care in the post-release period; provide motivational interviewing and harm 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 ARCH program to traditional medical case management.
- Document all client interventions/activities and referrals in electronic medical record and CareWare; 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; attend weekly BHCHP Behavioral Health Team Meetings
- Provide documentation for grants, projects, etc. as directed by the Supervisor; participate in intra-agency committees.
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, in addition to experiencing homelessness and struggling with substance use disorders and mental.
- Experience with harm reduction, trauma informed care, related services, and community resources.
- Computer proficiency; strong organizational skills
- Strong interpersonal and communication skills
- Experience with electronic health records is desired; experience with quality improvement processes is desired.
- Experience in trauma informed care, motivational interviewing, and harm reduction frameworks is desired; comfort working in outreach settings (street, shelters, etc.)
- Bilingual English-Spanish preferred
- Demonstrated interest in working with vulnerable populations, and 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, including (but not limited to) communities of color, LGBTQ communities, non-English speaking populations, people with histories of incarceration, people with substance use disorders and behavioral health challenges, and people experiencing homelessness.
- The compensation starts at $22.07 per hour and increases based on years of experience.
- BHCHP full time employees are eligible for our competitive time off policy of 4 weeks’ vacation, health, dental and vision insurance, 403B retirement savings plan and employer retirement contribution, and pre-tax MBTA pass program with 40% discount. In addition, eligible employees will receive yearly increases, additional compensation of seven thousand five hundred added to your base hiring rate for demonstrated bilingual proficiency and the opportunity to work with local hospitals and community health centers.
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.
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