Community Liaison Wrkr Lvl ll - 51020

Full Time | New York City, NEW YORK | 12 months
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Job Summary

Full Time

$101,349 Average salary of similar jobs | Check Salary...

Job Description

Marketing Statement

NYC Health + Hospitals/At Home reaches outside the walls of our hospitals and brings health care to patients where they live. With more than 600 dedicated employees, Community Care provides services including home care, community care coordination, and community-based care management to individuals managing chronic health conditions residing in Brooklyn, Manhattan, Queens and The Bronx.  

Job Description



With the support and supervision of the Care Coordination Assistant Director, the care coordinator will manage a panel of assigned members, providing field-based care coordination. The care coordinator is responsible for assessing, care planning, and connecting Health Home candidates/members to a variety of community-based services including but not limited to medical, substance use recovery oriented services, mental health services, medication management, housing support, transportation, peer support, and other member needs that may arise.




  • Provide daily oversight of an assigned panel of candidates/members, delivering interventions designed to reduce unnecessary emergency department (ED)/emergency room (ER) and inpatient (IP) utilization, increase connection to primary care, and demonstrate improved health outcomes for the served population.
  • Administer program requirements as defined by all applicable federal, state, local, and agency guidelines (e.g. assessments, care plans, documentation of services, etc.) and other Health Home documentation required to address member needs.
  • Monitor alerts (e.g. hospital admission/discharge, incarceration, ER/ED visit, etc.) and follow up with members promptly, verifying appropriate levels of care and access to all needed medications, therapies, and supports in managing care transitions.
  • Provide regular, field based face-to-face visits with members/candidates in home and/or community settings
  • Participate in case conferences to ensure that each member’s care team is aligned with a shared plan of care and up-to-date information on each member. Provide written status updates on a regular basis as requested (case conference tool, status update tools, emails, etc.) and verify documentation of all such activities in member chart.
  • Adhere to timeframes and quality standards regarding completion of member assessments, reassessments, care plans, and documentation (including case notes, updates, consents, etc.).
  • Manage schedule to allow for adequate field time, travel time, and time to complete administrative duties of position.
  • Maintain positive partnerships with providers and clinics internal to (and external to as necessary) NYC Health + Hospitals
  • Maintain a directory of provider services including medical, behavioral health, social support and other services as needed to support referral and coordination activities of assigned staff. Identify valuable resources to share with the rest of the team to the benefit of all members.  
  • Maintain positive and productive personal presentation within and outside of the assigned hub/office(s), ensuring all engagements with leadership, staff/coworkers, members, and community partners are professional, courteous, and respectful.
  • Proactively adhere to policies and procedures; participate in department/agency trainings/workshops as directed
  • Develop and maintain proficiency as a user of the Electronic Health Record System(s) of the agency; uphold all policy related to use of the system and documentation timeframes
  • Attend community meetings, committees, and trainings as requested; maintain and promote a positive image of the agency, department, and hub with the goal of fostering positive community relations to the benefit of the served members and agency mission at large.
  • May attend outside meetings or conferences and or other duties as deemed necessary.

    Minimum Qualifications

  • Two additional years of full-time experience in counseling, community work or community health activities in a government agency or community organization engaged in providing community services to the public, assisting members of the community in obtaining community services or maintaining liaison with schools, community organizations or other government agencies for the purpose of providing assistance and obtaining participation and support for implementation of community or public service programs; or
  • Education and/or experience equivalent to “1” above. Study at an accredited college in sociology, psychology or other behavioral science may be substituted on the basis of 30 semester credits for each year of the experience

  • Department Preferences

  • Bachelor’s degree in related field preferred
  • Minimum of 1 years’ experience in care coordination, care management, case work, with chronically ill, HIV/AIDS, homelessness, and/or substance abuse patients managing chronic health conditions and social needs
  • Proficiency in Microsoft Office Suite (including but not limited to Outlook, Word, Excel)
  • Proficiency/experience working within electronic health record (EHR) systems
  • Willingness and ability to regularly travel between assigned work sites

    How To Apply


    If you wish to apply for this position, please apply online by clicking the "Apply Now" button or forward your resume, noting the above Job ID #, to:
    NYC Health + Hospitals/At-Home
    Human Resources Department
    160 Water Street 9th Floor
    New York, NY 10038
    Attn: Recruitment Unit

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