Care Coordinator - Community Prevention & Treatment Services (Req 100940)

Be a part of the mission at Whitney Young Health (WYH) to provide high quality healthcare that is affordable and accessible to our diverse community.

WYH has a robust benefits package including generous time off, affordable health, dental and vision insurance, 401k with safe harbor employer match, tuition reimbursement, term life insurance, commuter benefits and more!

GENERAL RESPONSIBILITIES:

The Care Coordinator is a member of the Community Prevention and Treatment Services Team. This position works directly with patients who are living with infectious diseases and experiencing barriers to care and treatment. Populations served by CPTS Care Coordinators consist primarily of individuals facing social health disparities. This includes but is not limited to individuals living with HIV and/or Hepatitis C, individuals living with substance use disorder, members of the LGBTQIA+ community, and individuals seeking gender-affirming care. These services are provided to patients regardless of race, ethnicity, age, income status, gender expression and/or orientation, and sexuality. The CPTS Care Coordinator is responsible for assessing the needs of the patient throughout all stages of infectious disease medication management. This includes developing an individualized service plan, coordinating service delivery to meet the patient’s self-identified goals and addressing patient-specific challenges. The CPTS Care Coordinator participates in multidisciplinary team meetings in partnership with clinical staff to discuss patient needs on a weekly basis. The role of the Care Coordinator is to advocate on behalf of the patient and act as liaison to internal/external organizations providing whole-person care services.

SPECIFIC RESPONSIBILITIES:

• Actively manages a caseload of individuals living with infectious diseases.
• Develops comprehensive, individualized care plans and coordinates service delivery and activities required in implementing these care plans.
• Conducts face-to-face or over the phone intakes with individuals who are HIV or Hepatitis C positive in need of treatment/medication management.
• Performs Social Determinant of Health and Mental Health assessments with patients on a regular basis.
• Responsible for coordinating all aspects of medical care for members of caseload, including transportation to medical appointments, scheduling external specialty appointments, and any other patient-specific needs.
• Demonstrates knowledge of development across the lifespan, cultural and linguistic norms of minority populations and subpopulations, and awareness of socioeconomic health disparities as it pertains to medical and mental health treatment and prognosis.
• Interprets age-specific and cultural responses to treatment to improve health outcomes.
• Provides education, encourages retention in care, adherence to medical treatment, and strategies for promoting chronic disease self-management.
• Identifies the appropriate time for integrating family or the patient’s informal support network to help achieve clinical objectives.
• Manages referrals to appropriate agencies required to assist the client in achieving the goals and objectives identified in the Service Plan.
• Participates in case conferencing with the other members of the CPTS clinical team, as appropriate, and as required by acuity level.
• Participates in weekly HIV/HCV/PrEP Clinical Care Review
• Assist clients to access programs that will help pay for medical care and prescriptions.
• Conducts client-specific advocacy related to supportive services.
• Reviews clients’ utilization of services.
• Participates in outreach and engagement activities.
• Oversees transfer, inactivation, and discharge processes.
• Ensures timely documentation in the electronic health record and in designated State and Federal data management systems.
• Participates in Performance Improvement/Continuous Quality Improvement activities, as assigned.
• Demonstrates excellence in both internal and external customer service.
• Understands and is able to effectively communicate HIPAA compliance, corporate compliance and client confidentiality.
• Ensures and/or remains in compliance with local, state, and federal regulation, i.e. DHHS HRSA and NYSDOH, and all accreditation standards (e.g. Joint Commission and NCQA-PCMH).
• Adheres to the National Patient Safety Goals as defined by the Joint Commission and Whitney M. Young Jr. Health Center.
• Completes other duties as assigned.