Care Coordination Specialist

Housing Works was founded in 1990; With a long-term commitment to AIDS advocacy. Housing Works established New York State’s first harm reduction-based, OASAS-licensed outpatient drug treatment program. Other services include Health Home care management, behavioral health, and syringe exchange programs. A pioneer in the social entrepreneurship movement, Housing Works operates 10 high-end thrift shops in Manhattan and Brooklyn and a much-loved Bookstore Cafe in Soho. For more information, visit www.housingworks.org
Housing Works fights for funding and legislation to ensure that all people living with HIV/AIDS have access to quality housing, healthcare, HIV prevention, and treatment, among other lifesaving services.

Compensation Range: $23-$26/hour

Overview: The Care Coordination Specialist (CCS) is a vital member of our healthcare team, responsible for delivering comprehensive medical case management services to all Primary Care patients. The role is designed to ensure that patients receive coordinated, high-quality care from the moment they interact with our services. This position involves working collaboratively with clinical and support staff to manage patient enrollments, streamline referrals, document key patient interactions, and manage essential administrative processes within our Electronic Medical Record (EMR) system. The successful candidate will demonstrate exceptional organizational skills, clinical understanding, and a commitment to enhancing patient outcomes while supporting our mission to advocate for those affected by homelessness, substance use, and HIV/AIDS.

Responsibilities:

Patient Enrollment & Insurance Assistance:

• Coordinate the enrollment of uninsured patients with insurance programs, including facilitating ADAP (AIDS Drug Assistance Program) applications.
• Assist patients with various insurance authorization processes and paperwork.

Medical Case Management:

• Document hospitalizations and schedule discharge appointments as needed.
• Collaborate with internal clinical programs and support staff to monitor and communicate regarding client progress and referrals.
• Own care coordination tasks unless otherwise designated.

Communication & Documentation:

• Document significant issues discussed during morning huddles and telephone encounters in clinical meetings.
• Collaborate with the Nurse Manager (NM/RN) to create pre-huddle sheets that outline patient needs for provider follow-up.
• Ensure proper documentation and data entry in the EMR related to referrals and patient records.

Meeting Participation & Coordination:

• Actively participate in Morning Huddles and regular medical staff meetings, including Quality Improvement sessions.
• Provide coverage for the Patient Access Specialist (PAS) as needed.

Referral & Records Management:

• Coordinate all aspects of referrals initiated by health center providers, ensuring that:
  • Clients are aligned with a Primary Care Provider (PCP) before referral processing.
  • Appropriate structured data fields are updated within the referral tracking module in the EMR.
  • Patients receive all necessary paperwork for appointments, labs, x-rays, or other prescribed services.
  • Referral outcomes are tracked and communicated to the ordering provider.
  • Insurance authorizations are obtained when necessary.
• Complete medical records requests and upload relevant documents into patient charts.

Program Enrollment & Resource Distribution:

• Oversee the distribution of UND gift cards to eligible clients and accurately record receipt details in systems such as eCW and eIcare.

General Support & Advocacy:

• Provide professional assistance during patient registration and the scheduling of appointments.
• Support advocacy efforts aimed at addressing the challenges of homelessness and AIDS.
• Demonstrate commitment to the Housing Works Core values: Membership, All In, Stronger Together, and High Performance.
• Manage other duties as assigned by the Practice Manager, especially in a fast-paced environment with competing priorities.
• Understand and meet the needs of both internal and external customers by delivering effective service and escalating issues when required.