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About the Role

The Patient Navigator will provide care coordination services to members with chronic health conditions. This role acts as an intermediary between providers and members, serving as an educator, evaluator, service coordinator, and community resource researcher. The goal is to reduce emergency room visits and hospitalizations, improve service coordination, and assist with social service navigation.

Responsibilities

Provides case management services including weekly and monthly progress summaries, quarterly assessments, quarterly care planning, counseling, outreach, case conferences, advocacy, Targeted Case Finding, Naloxone training/Education/Dispensation, referrals, and discharge planning.
Completes initial assessment and quarterly reassessments on all assigned clients in a timely manner to develop individualized treatment goals.
Establishes treatment goals and objectives with clients as part of the interdisciplinary team.
Aids Case Manager in discussing, tracking appointments, documenting, educating, and engaging clients in PREP/PEP, STI/STD and HIV treatment services.
Ensures timely submission of clinical documentation to the care organization for uninterrupted services.
Facilitates harm reduction strategies support groups as needed.
Assesses client’s needs for services and cooperatively develops an integrated care plan and goals with the client, family, and other providers.
Coordinates transitional care from inpatient service to other settings as per the care plan.
Works collaboratively with team members to provide outreach and engagement for hard-to-reach clients.
Maintains documentation and updates care plans at specific time intervals or as needed in the Housing Works and Health Home electronic medical records system.
Assists clients to navigate the health insurance system including the AIDS Drug Assistance Program (ADAP).
Assists clients in navigation of internal and external medical systems.
Conducts field work to members’ homes and other provider settings as needed to fulfill the plan of care.
Participates in regular case conferences, huddle meetings, and IDT as needed.
Aids through advocacy and education to clients and families for entitlements and other community services.
Understands and is sensitive to chronic medical conditions, including HIV, mental health and substance use, diabetes, asthma, hypertension, heart disease and hepatitis diseases.
Consistently exhibits Housing Works core values of teamwork, advocacy and customer service.
Connects with external organizations to identify life-saving resource networks for clients disconnected from services.
Performs other duties as requested.
Participates in quality assurance and quality improvement planning projects and activities.
Participates in monthly peer workers development meetings and interventions.

Requirements

Bachelors’ Degree in social work or related field with at least two years of experience in a related social service field.
Ability to make data entries into programs database such as AIRS, e-Share, EiCare.
Good group facilitation skills and overdose prevention training experience.
Skilled with health insurance navigation and documentation.
Good verbal, written, communication and interpersonal skills.
Proficiency with computer software including Microsoft Office Suite (Word, Outlook calendaring, Excel).
Culturally aware and sensitive to PWUD (People Who Use Drugs), PLWHA (People Living with HIV/AIDS), LGBTQAI, YIDU (Young Intravenous Drug Users), SMI (Severe Mental Illness), and MSM (Men who have Sex with Men).
Minimum of 2 years of experience in care management.
Experience working with the adult population.
Ability to travel to member’s residence.
Knowledge of community health and social service agencies, public benefits, and additional community resources.
Frequently remaining in a stationary position, often standing or sitting for prolonged periods.
Occasionally moving around to additional worksites.
Occasionally lifting and moving objects up to 25 pounds in ordinary office-related tasks.

Skills

Care coordination
Case management
Client assessment
Treatment planning
Interdisciplinary team collaboration
Referral services
Discharge planning
Harm reduction strategies
Health insurance navigation
Electronic medical records systems
Advocacy
Outreach
Data entry
Group facilitation
Overdose prevention training
Microsoft Office Suite
Word
Outlook calendaring
Excel
Cultural awareness
Community resource knowledge
Public benefits knowledge

Location

New York City

Work Type

Onsite
Field Work

Experience Level

Commensurate with experience
Minimum of 2 years of experience of care management
At least two years of experience in a related social service field

Education Level

Bachelors’ Degree in social work or related field

Salary/Compensations

$21/hr - $24/hr

Benefits

Three comprehensive healthcare plans
PTO accrual up to 30 days in the first year
Educational benefit for tuition loan reimbursement, tuition costs, and textbooks

About the Company

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.
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.

Equal Opportunity

Housing Works provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics.
Housing Works complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities.
Housing Works also does not request prior salary information during the hiring process.
This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.
This position is included in a bargaining unit of Housing Works’ New York City employees represented by a labor union known as the Retail Wholesale and Department Store Union (“RWDSU”).