Woodhull Medical and Mental Health Center is attuned to the healthcare issues that matter to the people of North Brooklyn. Woodhull focuses on preventing disease and promoting healthy lifestyles by reaching out to the community at various convenient locations.

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.

8:00 A.M – 4:00 P.M

PURPOSE OF POSITION

Supports discharge planning activities overseen by Transitional Care Management Program: Transitions of Care team.

AREAS OF RESPONSIBILITIES

Case Management and Transitional Care Department

SUMMARY OF DUTIES AND RESPONSIBILITIES

1. Supports discharge planning activities overseen by Transitional Care Management Program: Transitions of Care team.
2. Promotes patient and caregiver engagement in decision making and care planning activities such as arranging for DME delivery, medication pick-up and delivery to med/surg units, and referring to system-wide or payor longitudinal care management or coordination programs.
3. Obtains post discharge primary and or specialty care follow-up appointments, including establishing patient with new provider as needed.
4. Provides telephonic follow up with patient, caregiver or community case manager to ensure adherence to primary or specialty care visit.
5. Documents each patient telephonic encounter in EMR utilizing patients’ preferred language and interpreter services as required.
6. Ensures demographic information is correct, accurate and updated in EMR (EPIC).
7. Assists the Accountable Care Managers with the coordination necessary for patients to obtain needed referrals, medications or resources during the care transition period.
8. Facilitates resources and arrangements required for safe transport to and from medical appointments as needed.
9. Provides verbal and written education of available transportation options, guidelines and benefits available to patient and caregiver.
10. Performs telephonic outreach to assist with identification of further needed care transition services.
11. Communicates clinical issues or social barriers to Clinical Care Teams, Accountable Care Managers, Social Worker, or supervisor, as appropriate.
12. Assists in addressing identified patient social needs through connection with appropriate resources and referrals through EPIC findhelp, NowPow, or BenefitsPlus in accordance with established policies.
13. Advocates for services that address care needs for patients enrolled in the Transitional Care Management Program, to inpatient and ambulatory care teams, healthcare systems, Insurers, and community providers, across the continuum of care.
14. Performs other related Care Management Program responsibilities as directed.
15. Supervises the performance of liaison activities; may be responsible for an administrative area covering multiple units.
16. Recommends procedures for implementation and maintenance of effective community liaison activities or community programs.
17. Directs research activities and provides for the dissemination of research data and materials to the Transitional Care Management Team.
18. Maintains communication with community groups; explains TCM program and policies.
19. Represents the hospital and TCM program or assigns representation at community resource events and activities.
20. Participates in planning, organizing and implementing overall community liaison programs.
21. Supervises staff development and training of community liaison employees.
22. Participates in ongoing education and specialized training to learn and maintain skills required for Transitional Care Management Program.
23. Performs field or office tasks as assigned.

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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