Care Coordinator-AIDS Center-Greenwich Village-Mount Sinai Hospital-Full Time-Days

Care Coordination is a Ryan White Part A funded program. Based on the case management model, it assists patients in accessing HIV care, communicating with providers, obtaining needed social services, and initiating or adhering to antiretroviral treatment while providing education and capacity-building to help patients become as self-sufficient as possible. As the population living with HIV ages, we increasingly serve geriatric care needs. 
 

The Care Coordinator is responsible for case-finding, program enrollment, routine assessment, support, coordination and guidance to people living with HIV from diagnosis to survivorship, in collaboration with the multidisciplinary clinic team, and through direct patient service and supervision of the programs’ Care Navigation Associates.
 

The Care Coordinator uses evidence-based research to formulate the plan of care and ensure that patients are following their protocols. Documents outcomes in the electronic health record and enters services in grant funder reporting system. Coordinates the appropriate resources and consult services to provide continuity of care and appropriate follow up. Communicates with all members of the healthcare team, in addition to external medical, social and supportive service providers and agencies. Initiates appropriate patient teaching based on needs. Supports the patient in decision making. Develops effective interpersonal relationships with patients and works collaboratively with the interdisciplinary care team to improve health outcomes. Utilizes internal and community resources, electronic medical record and data to educate patients and form a care plan with specific, measurable health outcomes.
 

• Supervising Care Navigation Associates (aka Patient Navigators) by supporting and monitoring completion of responsibilities including: appropriate and timely service delivery, health education delivery, case management, data entry, and tracking of patient progress;
• Identifying and enrolling eligible patients in collaboration with the interdisciplinary clinic staff, completing the comprehensive intake assessment and biannual reassessments, verifying patient eligibility, conducting clinical screenings and collecting relevant documentation;
• Developing and routinely updating a patient-centered care plan in collaboration with the patient and their care team;
  Providing services for patients as needed, including health education, case management, and accompaniments to medical and social services appointments;
• Conducting quarterly case conferences with each patient’s Primary Care Provider and participating in interdisciplinary collaboration;
• Tracking each patient’s progress over time and communicating changes to the rest of the patient’s care team and maintaining patient charts;
• Documenting all patient encounters in the Electronic Medical Record;
• Conceiving, implementing and co-facilitating supportive, social and educational groups for people living with HIV, especially older adults;
• Performing data collection and data entry as required by the program funder;
• Participating in Quality Improvement and Research initiatives as needed.
• Partners with families, patient care team and community resources to provide exemplary, well-coordinated, timely, compassionate care.
• Other activities as required.
   

   Masters degree in Social Work, Mental Health Counseling or other clinical professional degree.
 

• Experience documenting in an electronic health record preferred.
• 3+ professional experience in a health-related or HIV-related program
• 3+ years of case management experience
• 2+ years of supervisory experience

• Excellent verbal and written communication skills to communicate effectively with patients, staff, visitors and the public. 
• Ability to manage a team of 3-4 Community Health Advocates; strong supervisory skills, organization and follow-through.
• English and Spanish fluency strongly desirable.
• Intermediate computer skills including Microsoft Word, Excel, and Outlook.