DHS Care Coordinator Team Lead (Community Liaison ...

Empower 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 carelong-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 DescriptionThe Complex Care Coordinator Team Lead position is a grant-funded position within the NYC Department of Social ServicesDepartment of Homeless Services (DHS) Health Office. Under the direction of the Complex Care Coordination Program Manager the Care Coordinator Team Lead 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, as well as to assist with the overall administration and planning of the project. 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 a team of complex care coordinators and Harm Reduction Specialists (e.g. Peer Counselors) within the DHS Health Office who provide in-person engagement support as appropriate.The Complex Care Coordinator Team Lead 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 hospitals, primary care providers, and DHS employees on behalf of client to ensure patient-centered care coordination.•Manages a portfolio of DHS clients with complex health and social needs.•Supports overall program administration, development of standard operating procedures, and planning of the program. Including assistance with budget and invoice monitoring, assisting with the development and maintenance of standard operating procedures, and developing recommendations to support program improvements.•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: o submission of applications for wrap-around resources and intensive community-based services; o coordinating connections to primary care, specialty care, community services, andor mental health services; o supporting clients to attend medical appointments (including sending appointment reminders to relevant stakeholders and identifying and reducing barriers to clients' attendance); o reconnecting after missed appointments; o participating and conducting case conferences with clients' care teams and other key stakeholders.•Engages 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•Participates in field-based work in healthcare or community-based settings, as needed.•Accesses and update 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 care coordination team staff to ensure their tasks are completed appropriately and in a timely fashion, have regular team and individual check-in meetings, and monitor work and schedules; accompany staff on shelter visits as needed.•Collects and tracks data to support the achievement of client-centered service plans; participate in program quality improvement initiatives.•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 Qualifications1. Five 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 governmental agencies for the purpose of providing assistance and obtaining participation and support for implementation of community or public service programs; including one year in the supervision of persons performing duties as described above.2. A satisfactory equivalent. Study at an accredited college in sociology, psychology or other behavioral sciences may be substituted on a year-for-year basis for experience described in (1) above. However, all persons must have at least one year of full-time supervisory experience as described in (1) above.Department PreferencesKnowledge, 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 clearconcise 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 programssoftware: 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, andor preventive services.•Preferred, but not required: Basic knowledge of clinical terminology and health systems.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 weekRetirement Savings and Pension PlansLoan Forgiveness Programs for eligible employeesPaid Holidays and Vacation in accordance with employees' Collectively bargained contractsCollege tuition discounts and professional development opportunitiesMultiple employee discounts programs

Created: 2025-02-23