Care Coordinator - HUD

The Care Coordinator position is integral to our integrated care team, dedicated to delivering exceptional care coordination services to our patients. This role is particularly focused on collaborating with and continuously supporting individuals who are chronically ill or considered "high-risk" patients. The Care Coordinator will establish and maintain effective partnerships with patients, their families, caregivers, and with specialty providers, clinics, hospitals, and other healthcare providers. Additionally, they will liaise with community resources to ensure a cohesive approach to healthcare, guaranteeing that all aspects of a care plan, including referrals and support systems, are seamlessly integrated. The Care Coordinator will be responsible for managing and coordinating the care of clients in our transitional and safe haven facilities. This role involves assessing client needs, developing individualized care plans, facilitating access to services, and ensuring compliance with HUD grant requirements. The ideal candidate will have a strong background in healthcare, social work, or a related field and a passion for helping vulnerable populations.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Work directly with the referrals team to oversee the monitoring, tracking, and management of patient referrals, ensuring follow-through with recommended appointments. 
• Support patients in attending specialized referral appointments, addressing potential barriers to ensure consistent care. 
• Assist patients in managing their appointments at CFH Health Centers, including scheduling and cancellation, via telephone support.
• Provide internal referrals to other services within the organization, along with non-clinical community referral linkages, and monitor outcomes.
• Conduct targeted outreach to patients requiring follow-up care or screenings, leveraging phone communication to ensure timely healthcare interventions. 
• Monitor patient compliance with scheduled medical appointments, proactively contacting those who have missed appointments or disengaged from care to reconnect them with necessary services.
• Provide hands-on assistance to enable clients to find suitable housing, including accompanying clients to apartment viewings and conducting neighborhood research throughout NYC and surrounding areas. 
• Advocate on behalf of the veteran with landlords and brokers to overcome any issues or challenges to securing suitable housing. 
• Work collaboratively with community housing specialists to identify suitable housing. 
• Conduct housing inspections for identified units prior to financial assistance being requested.
• Utilize Motivational Interviewing, and Harm Reduction techniques to assist both veterans and young adults, singles and families who are homeless to resolve their housing crises and promote long-term housing stability
• Assist with housing search and placement. Provide hands-on assistance to enable participants to find suitable housing, including accompanying participant to apartment viewings and conducting neighborhood research throughout NYC and surrounding areas. Advocate on behalf of the participants with landlords and brokers to overcome any issues or challenges to securing suitable housing. Work collaboratively with URRH housing specialist to identify suitable housing.
• Maintain a caseload of up to 25 or more clients. 
• Support clients not only through care coordination but also by taking on duties that overlap with Housing Specialists, such as assisting with housing applications, landlord engagement, and connecting clients to stable housing resources.
• Perform other related duties and responsibilities as assigned; job tasks and responsibilities may be modified or expanded to meet organizational needs.

JOB QUALIFICATIONS

Education: 

• Bachelor’s degree in Social Work, Public Health, or a related field (preferred).

Experience:

• Minimum of 2 years of experience in housing services, case management, or a similar role.
• Previous experience providing services and exercising leadership in a culturally and linguistically diverse setting, with demonstrated success.
• Prior experience in a health care setting, preferably FQHCs, strongly preferred. 
• Knowledge of HUD regulations and experience with HUD-funded programs (preferred).
• Proficiency in using Electronic Health Records (EHR) systems or housing management software.
• Excellent organizational and communication skills.
• Ability to work effectively with a diverse population.
• Strong problem-solving skills and ability to respond to crises.

Skill Sets:

• Strong organizational skills: Able to manage diverse responsibilities and provide services at various sites.
• Ability to establish and maintain effective working relationships with colleagues, patients, and contracted providers of health care services.
• Strong problem-solving skills and ability to address issues professionally and effectively.
• Excellent oral and written communication skills needed to provide counseling to patients, document case work and provide training.
• Ability to work both independently and within a team environment.
• Bilingual English/Spanish strongly preferred

Pay: $60,000

Languages:

• Bilingual English/Spanish/French strongly preferred.