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Transitions of Care-Care Coordinator, Care Management Services



Reports to: Senior Director, Care Management Services

Function: Serves as member of the Transitions of Care Team at New York Presbyterian Hospital System providing time-limited intensive care coordination for high-risk patients. Responsible for outreach, engagement, and the development and implementation of a comprehensive care coordination plan for assigned caseload.


•Participates in daily huddles to confirm receipt of new referrals and provide updates on enrolled clients (engagement during hospital admission and post-discharge)
•Responsible for engaging clients at hospital bedside to provide program overview and obtain consents within 1 business day of referral
•Works in collaboration with NYP TOC team to conduct a comprehensive assessment identifying needs and barriers within 4 weeks of hospital discharge.
•Works with client and members of the care team to identify and prioritize client’s health care and psychosocial goals and develop a comprehensive care plan to achieve them.
•Responsible for overall management of client’s care plan, including coordinating all aspects of care; monitoring and supporting adherence to care plan goals, including medications and other treatments; and documenting care plan progress toward goals
•Identifies, facilitates and secures access to needed healthcare, social services benefits and community resources. Works in collaboration with other care team members and care providers, including behavioral health, disease care management, home care, social work and community based organizations, to help client achieve optimal health outcomes
•Facilitates follow-up care after hospitalization or emergency room visit
•Provides time-limited, motivational approaches to promote treatment adherence for chronic conditions and/or behavioral change to reduce risk factors.
•Works with family members and other collaterals of the client’s choice to facilitate planning or delivery of care
•Communicates with clients, their families and caregivers to support care plan goals and integrate care delivery
•Uses decision support tools and supervisory support to identify appropriate interventions and health care and social service needs
•As necessary, assesses domiciled client’s living conditions by conducting home visits
•Delivers housing placement services to clients by completing psychosocial assessments, the HRA 2010e and other appropriate housing applications, as well as securing safe haven if possible, stabilization bed, and ultimately permanent housing
•Documents all client-related contacts and activities within 2 business days of contact
•Refers clients for long-term Health Home Care Coordination and facilitates warm transfers to Health Home Care Coordinators.
•Regularly participates in weekly clinical conference to review client cases and progress
•Attends in-service training as requested
•Provides coverage as needed for other staff on the program team
•Duties as assigned by supervisor


A Bachelor’s degree in any of the following (Master’s degree preferred): child & family studies, community mental health, counseling, education, nursing, occupational therapy, physical therapy, psychology, recreation, recreation therapy, rehabilitation, social work, sociology, or speech and hearing; OR A Credentialed Alcoholism and Substance Abuse Counselor (CASAC); OR A Bachelor’s level education or higher in any field plus two years of experience in at least one of the following:

• Providing direct services to individuals with serious mental illness, Substance Use Disorder (SUD) or complex medical needs OR
• Linking persons who have been diagnosed with serious mental illness, SUD or complex medical needs to a broad range of services essential to successfully living in a community setting (e.g. medical, psychiatric, social, educational, legal, housing and financial services.)




Fax/mail/email a resume, cover letter and contact information for 3 professional references to:

Sharon Royer
Director of Human Resources and Information ManagementCare Management Services
Fax: (212)925-7958

Posted on 04/08/19; CVMHA ID #12731