Job DescriptionMarketing StatementEmpower Every New Yorker — Without Exception — to Live the Healthiest Life PossibleNYC Health + Hospitals is the largest public health care system in the United States. We provide essential outpatient, inpatient and home-based services to more than one million New Yorkers every year across the city's five boroughs. Our large health system consists of ambulatory centers, acute care centers, post-acute care/long-term care, rehabilitation programs, Home Care, and Correctional Health Services. Our diverse workforce is uniquely focused on empowering New Yorkers, without exception, to live the healthiest life possible.At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.Job DescriptionSUMMARY OF ESSENTIAL DUTIES AND RESPONSIBILITIES:The Complex Care Coordinator position is a grant-funded position within the NYC Department of Social Services/Department of Homeless Services (DHS) Health Office. Under the direction of the Complex Care Coordination Program Manager, the Complex Care Coordinator will be stationed at DHS's central office in downtown Manhattan and will coordinate closely with inpatient and outpatient providers throughout the H+H system. Their primary responsibility will be to coordinate care and services for a complex care coordination program serving the most vulnerable New Yorkers experiencing homelessness with complex care needs. They will be responsible for communicating and coordinating with community-based providers, clinicians, hospitals, shelter providers, and other city and state agencies to address the complex care needs of clients. Coordinators will identify coordination of care opportunities, develop, and monitor care plans; coordinate multi-stakeholder case conferences; and document client-level characteristics, interventions, and outcomes.ResponsibilitiesThe Complex Care Coordinator will work in collaboration with a multidisciplinary team of physician, social workers, agency workers, and other stakeholders to coordinate care, improve client engagement, and enhance client's self-direction by advocating for services to address their social and health-related needs and will be responsible for the following:
- Act as a professional liaison between hospitals, primary care providers, and DHS employees on behalf of client to ensure patient-centered care coordination.
- Manage a portfolio of DHS clients with complex health and social needs.
- Utilize a patient-centered approach to develop, implement, update, and monitor evidence-based, trauma-informed, person-centered care plans to ensure the delivery of high-quality health care and other services aligned with harm reduction principles.
- Engage with shelter provider staff and other key stakeholders to coordinate the complex care needs of clients.
- Collaborate with shelter staff and providers across settings/ institutions to address unmet health-related needs of clients, including:
- submission of applications for wrap-around resources and intensive community-based services;
- coordinating connections to primary care, specialty care, community services, and/or mental health services;
- supporting clients to attend medical appointments (including sending appointment reminders to relevant stakeholders and identifying and reducing barriers to clients' attendance);
- reconnecting after missed appointments;
- supporting prescription fills and refills; and
- participate and conduct case conferences with clients' care teams and other key stakeholders.
- Engage clients, partners, and care teams during inpatient stays and, where possible, emergency department visits both within H+H and in other health systems, to facilitate transitions back to shelter and engagement into outpatient care, as needed
- Complete DHS institutional referral or reasonable accommodations forms, as needed.
- Participate in field-based work in healthcare or community-based settings, as needed.
- Access and update care management or other data collection systems to document client information, interventions, and outcomes in accordance with established policies and procedures.
- Complete documentation as required in a timely fashion
- Collect and track data to support the achievement of client-centered care plans using assessment tools, surveys, and logs, as appropriate; participate in program quality improvement initiatives.
- Liaise with contacts at City and State health, mental health, and social service agencies, as well as hospitals, corrections facilities, and community-based organizations to gather relevant client information in accordance with established policies and procedures, and to schedule case conferences with relevant stakeholders when needed.
- Adhere to regulations relating to the maintenance of patient privacy and confidentiality and adhere to all institutional policies and procedures.
- Participate in ongoing education and specialized training to learn and maintain Complex Care Coordinator skills, as well as public health emergency response skills.
- Perform other duties as assigned.
Minimum Qualifications
- Master's Degree in Public Administration, Public Health, Health Care Specialization, Social Work, Psychology or related field; and
- Three (3) years of increasingly responsible experience in hospital or regulatory agency administration, with particular emphasis on development and evaluation of mental health delivery services; or
- Possession of a valid license and current registration to practice in a mental health field issued by the New York State Education Department (NYSED).
Department Preferences
- 2 years' experience in complex care, case management, care management, or related field if candidate has a bachelor's degree, OR 4 years' experience in complex care, case management, care management, or related field if candidate has an associate's degree
- Prior experience assisting people with complex care needs (for example, individuals experiencing homelessness, criminal-legal involvement, mental health diagnosis, substance use issues, and intellectual or developmental disabilities).
- Prior experience in care management, case management, healthcare, community work, or community health activities.
- Excellent communication and documentation skills, including verbal communication and clear/concise written communication skills.
- Ability and willingness to conduct occasional home visits (including street and shelters) and outreach activities within the assigned borough(s) of NYC.
- Familiarity with harm reduction principles across settings (medical, substance use), and complex care principles (person-centered, equitable, cross-sector, team-based, data-informed)
- Familiarity with the social services landscape within the five boroughs of New York City
- Familiarity with the following computer programs/software: Microsoft Suite, including Word, Excel, Outlook, and PowerPoint; Adobe Suite; and Zoom, Teams, and other virtual meeting platforms
- Personal experience with homelessness, behavioral health issues (including substance use), incarceration, or other components of the criminal legal system, foster care, and/or preventive services
- Basic knowledge of clinical terminology and health systems.
How To ApplyIf you wish to apply for this position, please apply online by clicking the Apply Now button.If applying online, please include your cover letter in the same file attachment with your uploaded resume.NYC Health and Hospitals offers a competitive benefits package that includes:
- Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
- Retirement Savings and Pension Plans
- Loan Forgiveness Programs for eligible employees
- Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
- College tuition discounts and professional development opportunities
- Multiple employee discounts programs