Job Description
Job Description
Marketing Statement
Empower Every New Yorker — Without Exception — to Live the Healthiest Life Possible NYC 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 Description 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 Coordinator Team Lead, 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, monitor service plans, coordinate multi-stakeholder case conferences, and document client-level characteristics, interventions, and outcomes. In addition, this role will supervise Harm Reduction Specialists (e.g., Peer Counselors) within the DHS Health Office who focus on client engagement.
Responsibilities The Complex Care Coordinator will work in collaboration with a multidisciplinary team of physicians, 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:
- Acts as a professional liaison between the DSS Health Office Care Coordination Program and DHS employees and contracted shelter staff on behalf of clients to ensure patient-centered care coordination.
- Manages a portfolio of DHS clients with complex health and social needs.
- Utilizes a patient-centered approach to implement, update, and monitor evidence-based, trauma-informed, person-centered service plans to ensure the delivery of high-quality health care and other services aligned with harm reduction principles.
- Engages with shelter provider staff and other key stakeholders to coordinate the complex care needs of clients.
- Collaborates 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; and
- participating and conducting case conferences with clients’ care teams and other key stakeholders.
- Participates in field-based work in healthcare or community-based settings, as needed.
- Accesses and updates care management or other data collection systems to document client information, interventions, and outcomes in accordance with established policies and procedures.
- Completes documentation, as required in a timely fashion.
- Supervises Harm Reduction Specialists to ensure the prompt and efficient delivery of engagement services and needed follow-up, including having regular individual check-in meetings, monitoring work and schedules, and accompanying staff on shelter visits as needed.
- Liaises 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.
- Adheres to regulations relating to the maintenance of patient privacy and confidentiality and all institutional policies and procedures.
- Participates in ongoing education and specialized training to learn and maintain Complex Care Coordinator skills, as well as public health emergency response skills.
Minimum Qualifications - Four years of full-time experience in counseling, community work or community health activities in a government agency or community organization engaged in providing community services to the public, assisting members of the community in obtaining community services or maintaining liaison with schools, community organizations or other government agencies for the purpose of providing assistance and obtaining participation and support for implementation of community or public service programs; or,
- Education and/or experience equivalent to (1 above). Study at an accredited college in Sociology, Psychology or other behavioral sciences may be substituted on a year-for-year basis for the experience described in (1 above). However, all persons must have at least one year of full-time experience as described in (1 above).
Department Preferences Knowledge, Skills, Abilities And Other Requirements - 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.
- Preferred, but not required: 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
- Preferred, but not required: Basic knowledge of clinical terminology and health systems.
How To Apply If you wish to apply for this position, please apply online by clicking the "Apply for Job" 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
Job Tags
Holiday work, Full time, Temporary work, New year, Remote job,