Empower Every New Yorker - Without Exception - to Live the Healthiest Life Possible

NYC Health + Hospitals is the largest public health care system in the United States. We provide essential outpatient, inpatient and home-based services to more than one million New Yorkers every year across the city's five boroughs. Our large health system consists of ambulatory centers, acute care centers, post-acute care/long-term care, rehabilitation programs, Home Care, and Correctional Health Services. Our diverse workforce is uniquely focused on empowering New Yorkers, without exception, to live the healthiest life possible.

At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.

Job Description

Care Transition social workers provide care transition interventions to patients and their families transitioning from an inpatient admission or ED visit back to the community. Care transition social workers help patients remain engaged in behavioral health care and primary care, coordinate supportive services, and help patients overcome barriers to managing health conditions.

General tasks and responsibilities will include:
• Engaging/enrolling patients into the program, typically at the time of an inpatient admission or ED visit
• Conducting community-based assessments and interviews to identify patient health goals and needs
• Linking patients to community-based social support programs
• Assessing and addressing health, social and service-related needs of assigned/identified patients and create individualized, patient-centered, goal-directed plans for each patient
• Supporting and motivating patients to achieve their health goals by coaching them through behavior change and identifying their strengths and community support systems
• Helping patients connect to a primary care provider, specialty care providers, community services and/or mental health services, attend medical appointments, and fill prescriptions
• Assessing ability of patients to manage their chronic behavioral health condition(s) and work with care team to connect them to appropriate education and monitoring programs
• Assisting patients with social needs such as food insecurity, housing issues, legal needs, insurance or other health care coverage, or transportation and provide referrals and follow-ups, as needed (for example, helping patients fill out benefit applications)
• Educating patients regarding available community services, health services, and patient rights; provide feedback from patients to NYC H+H to inform quality improvement efforts
• Collecting and tracking data to support achievement of patient-centered care plan using assessment tools, surveys, and logs, as appropriate
• Documenting each patient encounter in the electronic medical record (Epic) and use other electronic systems (e.g., NowPow) in accordance with established policies and procedures
• Attending regular team meetings to discuss patient progress and update care plans; communicate with patients' behavioral health and primary care providers
• Perform other, related program tasks, as needed and perform duties in response to public health emergencies, when necessary

Minimum Qualifications

Valid license as an LCSW issued by the NYSED.

Department Preferences

KNOWLEDGEABLE IN:
• Communities served by NYC Health + Hospitals
• Community resources and levels of behavioral healthcare
• Social Determinants of Health

PREFERRED SKILLS:
• Prior experience in Care Transition or Care Management in a health care and/or Managed Care setting strongly preferred
• Confident, autonomous, solution driven, detail oriented, high standards of excellence, nonjudgmental, diplomatic, resourceful, intuitive, dedicated, resilient and proactive
• Excellent verbal and written communication skills including motivational coaching, influencing and negotiation abilities
• Bilingual is a plus
• Cultural competency
• Ability to communicate empathy

YEARS OF EXPERIENCE:
• Two years of full-time, paid, professional experience providing direct client care in a behavioral health setting
• Prior experience in Care Management in a health care and/or Managed Care setting strongly preferred

If applying online, please include your cover letter in the same file attachment with your uploaded resume.

NYC Health and Hospitals offers a competitive benefits package that includes:

• Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
• Retirement Savings and Pension Plans
• Loan Forgiveness Programs for eligible employees
• Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
• College tuition discounts and professional development opportunities
• Multiple employee discounts programs