NYC Health + Hospitals is the largest public health care system in the nation. We are a network of 11 hospitals, trauma centers, neighborhood health centers, nursing homes, post-acute care centers, and correctional health services. We are a home care agency and a health plan, MetroPlus. Our health system provides essential services to 1.4 million New Yorkers every year in more than 70 locations across the city's five boroughs. Our diverse workforce of more than 42,000 employees are uniquely focused on empowering New Yorkers, without exception, to live the healthiest life possible. Visit us at nychhc.org and stay connected on facebook.com/nycHHC or Twitter@hhcnyc.

NYC Health + Hospitals/Correctional Health Services is one of the nation's leading correctional health care systems in quality of and innovations to care, and access from pre-arraignment through compassionate release. In-jail services include medical, nursing, mental health, substance use treatment, social work, dental and vision care, discharge planning, and reentry support. In addition to providing direct patient care in the jails, CHS leverages the resources of the nation's largest municipal health care system to help discharged patients successfully return to their communities. CHS is also a pivotal partner in New York City's criminal justice reform efforts.

Job Description

Summary of position:

Elder Services aims to support individuals 55+ years of age who are incarcerated by providing jail-based support, discharge planning, and post-release follow-up. Under direction of the Director of Elder Services, the case manager will meet with patients to complete screenings and intakes for the service, as well as engage in follow-up related to patient-indicated areas of need. Each case manager will maintain a case load of patients and meet with those patients throughout their incarceration (regardless of facility).

Responsibilities include:
• Complete screening tools and intake assessments for patients assigned to case load.

o Provide production list to facility HSA; meet with patients in clinic to complete interview and obtain consents.

o Meet with patients in housing area (DOC escorts not provided; staff may travel in pairs/groups; seek support and supervision around patient prioritization and safety)

o Complete document in electronic medical records system (CHER) within 24 hours of encounter; scan and upload relevant consents and documents.

o Escalate any urgent issues to supervisor.
• Complete applications for Medicaid and other benefits programs as appropriate.

o Obtain relevant consents during patient encounter

o Submit applications online using HRA or other platforms.

o Confer with supervisor when needed
• Create individualized discharge plans for each patient according to the patient's goals and needs and ensure tasks are completed. Tasks may include, but are not limited to: coordinating medical appointments, ensuring medications are called into a pharmacy, making referrals to housing and case-management resources, and confirming transportation between jail and community dwelling is arranged.

o Develop plan with patient; discuss in team rounds and supervision when needed.

o Communicate with community organizations/providers directly, via email or phone; escalating to supervisor when appropriate.

o Review plan with patient prior to discharge, when discharge date is known.
• Provide ongoing in-jail support to patients, meeting with them regularly; frequency to be decided in consultation with Program Director.

o Interventions focus on addressing public health issues that effect the elder populations: homelessness, limited social networks, physical health concerns.
• Serve as conduit between patient and clinical court advocates, and assist as needed with obtaining consents, relaying information, and other tasks.

o Under direction of supervisor, communicate directly with court advocacy team, primarily by email; and/or escalate cases to supervisor.

o Based on needs of court advocacy team, obtain additional information and consents when requested.
• Attend weekly team rounds and participate in patient case conferences with other discharge planning program staff.

o Prepare patients/cases to discuss

o Complete assignments generated from team discussion; follow-up with supervisor
• Conduct post-release follow-up outreach to patients, via telephone, and assist or make additional referrals as appropriate.

o Attempt to contact all patients within 24 hours of release, calling all phone numbers provided on consent.

o Troubleshoot issues (e.g., pharmacy issues, medical appointments, referrals) as able; confer with supervisor as needed.

o Document in CHER.
• Document screening tool, intake assessment, transition plan and collateral information in the electronic health record (CHER).
• Additional tasks and projects as requested by Program Manager and/or Director of Special Populations.

Minimum Qualifications
1. A four-year high school diploma or its educational equivalent and four (4) years of satisfactory full-time experience providing direct counseling, guidance, crisis-intervention or information and referral services for inmates of a correctional facility, substance abusers or a similar client population; or
2. Education and experience equivalent to "1" above. Thirty (30) semester credits from an accredited college will be considered equivalent to one (1) year of the required experience. However, all candidates must have a four-year high school diploma or its educational equivalent and at least one (1) year of experience as described in "1" above.

If you wish to apply for this position, please apply online by clicking the "Apply Now" button or mail your resume, noting the above Job ID #, to:

NYC Health + Hospitals / Correctional Health Services
Talent Acquisition
Human Resources Department
55 Water Street, 18th Floor
New York, NY 10041
Attn: Talent Acquisition

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