Patient Care Navigator - Primary Care & Social Services

HOUSING WORKS INC; New York (NY); On-site; USD 50,000 - 55,000; Full time

Benefits offered by this job

Healthcare plans

PTO up to 30 days

Tuition assistance

Job summary

Housing Works is seeking a Patient Care Coordinator in New York to screen patients, verify insurance, and provide medical case management for Primary Care patients.

You will coordinate intake screenings for eligibility across ADHC, OASAS, Health Home, RAD, OMH, and PrEP, perform PRAPARE assessments, and coordinate referrals with the care team. Proficiency in EMR and HIPAA, plus Spanish, are preferred, with flexible hours and a focus on advocacy.

Qualifications

• Bachelor’s Degree preferred.
• Strong understanding of HIV/AIDS, case management, and entitlements.
• Ability to identify medical emergencies, promptly notifying the appropriate medical and clinical personnel for assistance.
• Solid knowledge of Microsoft Office Suite.
• Solid knowledge of HIPAA regulations regarding medical document requests is required.
• Strong organizational and clinical skills are essential.
• Proficiency in Spanish and experience with Electronic Medical Record (EMR) systems are preferred.
• Ability to work flexible hours, including 9 AM-5 PM on non-late clinic days, 11 AM-7 PM on late clinic days, and weekend shifts from 9 AM-5 PM
• Preference for individuals with experiencing working in a community-based setting, particularly with patients who are LGTBQIA+, and/or have experienced homelessness, substance use, and/or mental health challenges

Responsibilities

• Coordinate intake screenings to determine patient eligibility for ADHC, OASAS, Health Home, RAD, OMH, PrEP, and other relevant services.
• Work with the Intake Specialist to ensure PRAPARE assessments are completed during annual visits.
• Ensure new patient leads are generated in eICare.
• Administer PRAPARE assessments (Social Determinants of Health tool) and provide referrals for Primary Care clients, including care coordination and case management referrals.
• Coordinate with the care management team for sub-specialty and other clinically related referrals for all Primary Care clients.
• Participate in bi-monthly one-hour interdisciplinary meetings and transcribe minutes for monthly one-hour Quality Improvement meetings.
• Document hospitalizations and schedule discharge appointments as needed.
• Collaborate with Program Partners and clinical/support staff to discuss client progress and referrals.
• Organize regular on-site meetings with case managers to review the status of dually enrolled clients.
• Maintain documentation of significant client progress and discussion points during morning huddle and other clinical.
• Participate in morning huddles and regular medical staff meetings, including Quality Improvement initiatives.
• Work with the Nurse Manager (RN) to create pre-huddle sheets addressing patient follow-up needs.
• Document clinical interventions in Primary Care medical records.
• Coordinate with ancillary programs (e.g., OMH, ADHC, OASAS) to conduct client outreach activities.
• Serve as the primary point of contact for care coordination, unless otherwise designated.
• Support and participate in advocacy efforts to combat homelessness and AIDS.
• Assist medical providers with necessary paperwork for clients, including but not limited to: Transportation forms (2015 Form) Home Health Aide requests (M11Q Form) HASA, Utilization Threshold, and Restriction requests Non-clinical letters and verification documents
• Process paperwork as requested and ensure proper documentation in the Electronic Medical Record (EMR).
• Provide coverage for the Patient Service Representative as needed.
• Perform other duties as assigned by the Health Center Director or Clinic Operations Manager.
• Uphold and practice Housing Works' core values: Membership, All In, Stronger Together, and High Performance.
• Adapt to a fast-paced environment, assisting in other roles as needed based on priorities.
• Manage local Medical Records Releases, ensuring a 10-day turnaround for processing.

Skills

Case management

HIPAA compliance

Microsoft Office

Spanish language

Education

Bachelor's degree

Tools

EMR systems

Job description

Housing Works is seeking a Patient Care Coordinator in New York to screen patients, verify insurance, and provide medical case management for Primary Care patients.

You will coordinate intake screenings for eligibility across ADHC, OASAS, Health Home, RAD, OMH, and PrEP, perform PRAPARE assessments, and coordinate referrals with the care team. Proficiency in EMR and HIPAA, plus Spanish, are preferred, with flexible hours and a focus on advocacy.