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Patient Care Coordinator – Care Coordination Program
Care Coordination is a program based on the case management model that 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 self-sufficient.
The Patient Care Coordinator enrolls, regularly assesses, and provides ongoing support to Care Coordination patients in collaboration with the multidisciplinary clinic team through both direct patient service and supervision of the Community Health Advocates.
Job responsibilities include:
· Supervising 3-4 Community Health Advocates (Patient Navigators) by supporting and monitoring completion of all responsibilities including appropriate and timely service delivery, health education delivery, case management, data entry, and tracking of patient progress;
· Providing services for patients as needed, including health education, case management, and accompaniments to medical and social services appointments;
· Identifying and enrolling eligible patients in collaboration with the interdisciplinary clinic staff;
· Verifying patient eligibility and collecting relevant documentation;
· Developing a patient-centered care plan in collaboration with the patient and their care team;
· Completing the comprehensive intake assessment and biannual reassessments with all enrolled patients;
· Conducting quarterly case conferences with each patient’s Primary Care Provider;
· Participating in interdisciplinary collaboration;
· Tracking each patient’s progress over time and communicating changes to the rest of the patient’s care team;
· Maintaining patient charts;
· Documenting all patient encounters in the Electronic Medical Record;
· Performing data collection and data entry as required by the program funder;
· Participating in Quality Improvement and Research initiatives as needed.
Applicants must have the following qualifications:
· Bachelor’s degree or equivalent education or work experience
· Interest in working with a high-needs HIV+ patient population
· Ability to travel throughout New York City by public transportation and comfort with conducting home visits in all of the five boroughs
· Computer skills
· Exceptional interpersonal skills and cultural competency
· High level of organization and attention to detail
· Ability to manage a complex work schedule
· Ability to supervise a team of 3-4 Community Health Advocates
Preferred qualifications include:
· Spanish and English fluency
· Master’s or other advanced degree in Social Work, health education, or a related field
· 4+ professional experience in a health-related or HIV-related program
· 4+ years of case management experience
· 2+ years of supervisory experience
· Experience documenting encounters in a medical record
Description of the Institute for Advanced Medicine:
As part of the Mount Sinai Health System, the Institute for Advanced Medicine (IAM) is a newly integrated organization that will provide comprehensive, state-of-the-art treatment to patients living with HIV/AIDS. We unite the Health System’s outstanding physicians and staff from multiple disciplines into one integrated program that provides accessible, affordable, and expert primary and specialty care to HIV patients, and their friends and families throughout the New York metropolitan area. We have six fully integrated practice locations, so whether you are HIV positive or wanting to stay negative, we will help you.