Housing Coordinator
Job Summary
The Housing Coordinator provides clinical, administrative, and educational supervision to a team of up to five Housing Specialists and/or direct service staff. This role ensures the delivery of high-quality, client-centered housing services for individuals living with HIV/AIDS and facing housing instability. As part of the Direct Service Unit Coordinator team, the Housing Coordinator also provides backup administrative and clinical coverage, supporting seamless service delivery and staff development across the unit.
Essential Functions
Supervision
• Supervise the housing team, monitoring the timeliness and quality of Housing Medical Case Management services and reports.
• Provide clinical, administrative, and educational supervision for up to 5 housing specialists and/or direct service staff.
• Support staff development through coaching, orientation, and ongoing in-service training.
• Conduct weekly supervision meetings with housing staff to review cases for thoroughness and compliance; complete supervisory logs and one chart review per staff member.
• Schedule and lead monthly group meetings to share agency updates, facilitate case reviews, and deliver educational presentations.
• Monitor staff caseloads to ensure alignment with job titles and verify that performance measures—including client contact, assessments (ClientTrack & CaseWorthy), and housing plans— are consistently met.
• Ensure timely and thorough completion of screenings, housing and RAP/CAP assessments, Service Care Plans, and treatment adherence documentation by Housing Medical Case Managers.
• Foster a collaborative, client-centered approach to housing services.
Administrative & Clinical Coverage
• Ensure compliance with organizational policies, procedures, and regulatory requirements.
• Document client-related interactions in the client database(s) in a timely and accurate manner.
• Coordinate and oversee the collection of client information, ensuring confidentiality in reporting and recording.
Support and Coordination
• Assist in the development and implementation of the housing department, including service provision, staff orientation, and ongoing training.
• Contribute to data collection, reporting, and evaluation of housing outcomes.
• Promote best practices in housing stability, case management, and client engagement.
Collaboration and Communication
• Interface with housing and homeless service providers to coordinate care and strengthen service networks.
• Provide point of contact for consultation and follow-up with social service providers in discharge planning and home care plans.
• Provide advocacy around housing issues and keep direct service staff informed of relevant housing issues affecting the client base.
Coaching and Performance Management
• Provide ongoing coaching and feedback to assigned staff to support professional growth, skill development, and service excellence.
• Conduct formal performance management reviews in alignment with agency standards, including goal setting, progress evaluation, and documentation of outcomes.
• Ensure performance reviews are timely, constructive, and aligned with organizational goals and values.
Timesheet Oversight and Accuracy
• Review assigned staff timesheets regularly to ensure accuracy, completeness, and compliance with agency policies.
• Verify recorded hours against scheduled work. Review ADP’s Time and Attendance dashboard and make adjustment(s) as needed.
• Ensure timely submission and approval of timesheets to support payroll and reporting process.
Education and Experience
• Bachelor’s degree in Social Work, Human Services, or related field.
• Master’s degree preferred, particularly in Social Work (MSW), Counseling, Public Health, or Housing-related disciplines.
• Minimum of four (4) years of experience in housing case management, supportive services, or program coordination for individuals affected by HIV/AIDS, homelessness, or behavioral health conditions.
• Supervisory experience with direct service staff strongly preferred.
Medical Case Manager
Job Summary
The Medical Case Manager provides the full range of case management services to a caseload of approximately 45-55 HIV positive clients. This role works as an integral member of the Direct Services team to ensure clients receive high-quality, comprehensive, and coordinated care. Responsibilities include assessing client needs, developing individualized care plans, linking clients to medical and supportive services, monitoring progress, and advocating for resources to promote optimal health outcomes. The Medical Case Manager fosters a supportive and respectful environment, empowering clients to actively engage in their care and improve their quality of life.
Essential Functions
- Serve as the primary medical case manager for individuals and families impacted by HIV/AIDS, providing comprehensive support and care coordination.
- Evaluate client needs and create, implement, and track individualized care plans to ensure effective service delivery.
- Connect clients with appropriate medical, mental health, substance use, and supportive services to address their comprehensive needs.
- Coordinate referrals to medical, mental health, addiction recovery, and ancillary support services.
- Attend at least one medical visit per year with each client to ensure continuity of care, support and advocacy.
- Oversee and track service delivery while supporting clients in advocating for and obtaining entitled benefits.
- Conduct needs assessments, design tailored service plans, and monitor progress toward client goals.
- Identify client needs, establish personalized care strategies, and oversee their ongoing implementation and outcomes.
- Deliver on-site case management services in clinic or hospital settings as required.
- Conduct in-home assessments and provide services when appropriate.
- Maintain up-to-date knowledge of available services, benefits, and entitlements to support client referrals and advocacy.
- Maintain at least 450 monthly service units, calculated in 15-minute intervals.
- Complete required paperwork for client interactions and referrals in accordance with established Direct Service policy deadlines.
- Ensure all performance measures, including client contacts, screenings, and service plans, are consistently achieved.
- Maintain and record at least the minimum required client contacts within the timeframes specified in the Direct Services Policy and Procedure Manual.
- Complete timely written records of client contacts no later than two business days after each interaction.
- Work in partnership with other service providers and community agencies to coordinate comprehensive care.
- Provide guidance, educational resources, and referral services to clients and their families or caregivers.
- Serve as an informational and advocacy resource on AIDS-related topics within the community.
- Apply a strengths-focused perspective in all client interactions to promote empowerment and resilience.
- Cover intake responsibilities as needed to facilitate access to services.
- Attend required meetings, including Direct Services, in-service trainings, and general staff gatherings.
- Attend and actively participate in monthly group supervision meetings.
- Participate in supervision, engaging in weekly individual and monthly group sessions.
Perinatal Case Manager
Job Summary
The Perinatal HIV Case Manager provides comprehensive case management services to a caseload of approximately 35–40 HIV-positive clients, including pregnant individuals, in both clinical and office-based settings. This role is integral to efforts aimed at reducing vertical transmission of HIV by coordinating care, supporting treatment adherence, and ensuring timely access to prenatal and HIV-related services. The Case Manager works collaboratively with HIV and OB providers, as well as other program staff, to deliver high-quality, client-centered care as part of the Direct Services team.
Essential Functions
- Serve as the medical case manager for individuals, pregnant women, and families impacted by HIV/AIDS, providing comprehensive support across clinical and community settings.
- Conduct needs assessments and develop, implement, and monitor individualized Service Care Plans tailored to each client’s circumstances.
- Connect clients to appropriate medical, mental health, housing, immigration, legal, substance use, and social support services.
- Coordinate and monitor service delivery, assisting clients in advocating for entitlements and public benefits, including prescription and utility assistance programs.
- Provide on-site case management in clinics and hospitals as needed to support continuity of care.
- Advocate proactively for clients, utilizing all available resources to address barriers and support access to care.
- May be responsible for creating and maintaining resource lists relevant to perinatal and HIV-related services.
- Attend a minimum of five perinatal medical appointments, one postpartum visit, and two HIV specialist appointments per client to support engagement in care.
- Conduct home visits twice annually to assess living conditions and provide additional support.
- Assist clients with transportation coordination to ensure access to essential services.
- Collaborate with external service providers and agencies, including the Department of Human Services (DHS), to ensure integrated care.
- Offer education, information, and referrals to clients and their support networks to promote informed decision-making.
- Represent the agency at community events, including outreach efforts such as baby showers, to raise awareness and connect with potential clients.
- Maintain up-to-date knowledge of resources, benefits, and entitlements to effectively refer clients and advocate for their needs.
- Achieve a minimum of 450 units of service per month (measured in 15-minute increments), meeting productivity expectations.
- Complete written documentation of all client interactions within two business days, in accordance with agency standards.
- Ability to manage a caseload of 35–40 clients, meeting service unit goals and documentation deadlines.
PLP Intake & Assessment Specialist
Position Title: Intake & Assessment Specialist
Reports To: Prison Linkage Program Coordinator
Department: Direct Services
Program: Philadelphia Linkage Program (PLP)
Status: Full-time Monday through Friday, Nonexempt, Eligible for benefits
Qualifications:
- Minimum Bachelor’s degree, Master’s preferred, in social work or related field.
- Experience in human service delivery, case management, assessment and client advocacy.
- Understanding of the medical and psycho-social issues related to living with HIV/AIDS.
- Bi-lingual (Spanish/English) and experience in corrections a plus. Ability to work with diverse populations.
- Working knowledge of local resources. Ability to work with various professionals, including medical, non-medical, and Para-professional staff in the case management and prison system.
- Eligible to enter the correctional facilities as a contract employee.
Basic Function:
- Provide intake and assessment case management services to individuals currently incarcerated.
- Assess, address and provide consultation to other staff regarding prison issues on an as needed basis.
- Serve as a liaison with the staff of Prison Health Services, Corizon, Defenders Association, court officers, probation and parole offices.
Specific Responsibilities:
- Accept referrals from various sources for services to incarcerated individuals
- Perform face-to-face needs assessment.
- Complete a service care plan with the client
- Maintain accurate and timely activity logs.
- Obtain updated medical and demographic data and informed consent of each client.
- Maintain a reduced caseload and provide case management and advocacy to the HIV+ individuals who are incarcerated or have recently been released from prison. This includes being available to visit the client at the prison, home, in the hospital and office visits.
- Assist clients in negotiating, arranging and linkage to medical care, social services and other provider systems. Provide the client with information and referral, arrange necessary services. Follow up and monitor the support system on a monthly basis. Reassess client need as appropriate.
- Work with care providers in the areas of hospital discharge planning and home care needs.
- Provide specialized case management and advocacy by carrying a caseload of individuals whose primary presenting problem is being symptomatic of HIV disease and reentry to society following incarceration.
- Evaluate the need and assist clients to be admitted to substance abuse and/or mental health treatment.
- Consult with other members of Action Wellness staff including direct service staff, housing specialist, prevention case managers, volunteers and others as needed.
- Identify resources and communicate with agencies and organizations providing services to incarcerated and recently incarcerated individuals.
- Attend weekly one on one supervisory meeting.
- Participate in Action Wellness staff meetings and in-service trainings.
- Participate in required in service and off-site trainings and staff development.
- Attend a minimum of 2 medical appointments.
LEAP Case Manager
The LEAP Case Manager plays a vital role in supporting individuals impacted by incarceration in Philadelphia. This position Connect clients to housing, healthcare, employment, and community-based services to promote successful reintegration. Provide consultation to staff on prison‑related issues as needed. Serve as a liaison with YesCare staff, the Defenders Association, court officers, and probation and parole offices.
This role assists individuals currently incarcerated or recently released from the Philadelphia County Prison system who have a diagnosis of opioid use disorder, helping them access resources, navigate systems, and achieve stability.
Essential Functions
- Conduct in-person needs assessments to identify client strengths, challenges, and service requirements.
- Develop and update individualized service care plans on a quarterly basis in collaboration with each client.
- Maintain accurate, up-to-date activity logs in accordance with program requirements.
- Collect and update medical and demographic information, securing informed consent from each client as required.
- Provide case management and advocacy services to individuals who are incarcerated or recently released from prison, including availability for visits in correctional facilities, hospitals, homes, and office settings.
- Facilitate access to HIV prevention services including PrEP, PEP, and HIV testing.
- Provide navigation support to ensure clients seeking HIV prevention services can overcome barriers to care.
- Connect clients to medical care, social services, and provider networks to address comprehensive needs.
- Offer information, referrals, and service coordination to arrange appropriate resources and supports.
- Conduct ongoing reassessments to evaluate and respond to changing client needs.
- Collaborate with healthcare providers to support hospital discharge planning and address home care needs.
- Deliver specialized case management and advocacy for a caseload of individuals whose primary needs include opioid use disorder treatment and successful reentry following incarceration.
- Assess client needs and facilitate admissions into appropriate substance use and/or mental health treatment programs.
- Engage in team collaboration by consulting with Action Wellness staff, including direct service providers, housing specialists, volunteers, and other colleagues as necessary.
- Identify and coordinate resources by engaging with agencies and organizations that serve incarcerated and recently released individuals.
- Stay informed about available resources, benefits, and entitlements to effectively advocate for clients and provide appropriate referrals.
- Complete all required paperwork, documentation, and referrals within the timeframes established by the Direct Services Policy and Procedure Manual.
- Record client contacts promptly in accordance with documentation standards outlined in the Direct Services Policy and Procedure Manual.
Housing Specialist
Job Summary
The Housing Specialist provides comprehensive direct services to individuals and families facing housing instability. This includes identifying housing resources, navigating homeless services, and assisting with rental and utility assistance programs. The role also serves as a key support for clients residing in subsidized housing, helping them maintain stable housing, set goals toward permanent housing, and monitor progress. The Housing Specialist works collaboratively with clients and service partners to promote housing security and long-term self-sufficiency.
Essential Functions
- Conduct intake and face-to-face needs assessments with clients, collecting eligibility documentation including verification of disability, proof of homelessness, housing demographics, and informed consent.
- Collaborate with clients and their support teams to develop individualized housing plans, while maintaining strict confidentiality.
- Consult with homeless service providers during intake to enroll clients, expedite transfer requests and for discharge planning.
- Provide specialized housing counseling and advocacy for individuals who are disabled due to HIV disease, who identify housing as a primary concern, managing an active caseload.
- Assist clients in locating housing within local Fair Market Rent guidelines, and connect them to housing services, utility assistance programs, and budget counseling.
- Monitor rental and utility payments monthly, reassessing client needs and adjusting plans as appropriate.
- Engage with landlords to support lease negotiations, lease signing and housing inspections.
- Complete required rental calculations, program agreements, lease addendums, annual re-certifications, along with rental suitability where applicable.
- Ensure all client contacts, referrals, and service documentation are completed in accordance with timelines outlined in the Direct Service Policy and Procedure Manual and funding requirements.
- Provide training to Action Wellness staff and volunteers on housing-related topics, and maintain updated agency resources on housing and utility programs.
- Educate clients on tenant rights and responsibilities, housing programs, and available resources.
- Offer referrals and educational support to clients and their families as needed.
- Build and maintain strong relationships with local housing providers, community development organizations, and public housing agencies at the city and state level.
- Maintain up-to-date knowledge of housing resources, benefits, and entitlements to effectively refer clients and advocate for their needs.
- Meet the agency’s minimum standard of 450 units of service per month (measured in 15-minute increments).
- Complete all intake documentation in Case Worthy and HMIS, along with related paperwork within 24 hours of client encounters.
- Maintain and document minimum required contact with each client on the caseload, following agency standards.
