Care Coordinator

GMHC•New York, NY

12d•Hybrid

About The Position

The Care Coordinator provides direct service leadership for Ryan White Care Coordination participant enrollment and ongoing care coordination. The Care Coordinator conducts intakes and assessments, supports development and monitoring of care plans, coordinates referrals and service linkages, and ensures timely, accurate documentation that supports program deliverables. The Care Coordinator also supervises Patient Navigators and supports consistent workflow practices aligned with agency and funder expectations.

Requirements

Strong understanding of barriers for underserved and historically marginalized communities.
Experience working in a fast-paced, data-driven, performance-based environment.
Ability to work independently and apply critical thinking to support program goals.
Exceptional active listening skills and interpersonal skills, with the ability to communicate effectively and professionally across diverse audiences.
Experience working with vulnerable populations, including individuals with chronic health conditions, HIV/AIDS, substance use disorders, mental health concerns, limited English proficiency, or lack of insurance.
Ability to work effectively and efficiently within an interdisciplinary team.
Commitment to providing trauma-informed, culturally responsive, and client-centered services.
Cultural humility and demonstrated ability to work effectively with diverse communities, including individuals with complex health and social service needs, and LGBTQ+ populations.
Ability to manage deadlines and documentation requirements in a compliance-driven program environment.
Bilingual English and Spanish fluency, with the ability to clearly communicate complex information to clients and community partners.
High School Diploma, G.E.D., or H.S.E. or equivalent required.
Must be bilingual (English and Spanish).
Intermediate proficiency in Microsoft Excel, including: Creating and managing spreadsheets to track client enrollments and renewals. Using formulas, pivot tables, and data validation to ensure accuracy in documentation. Organizing outreach and referral data for trend analysis.
Basic Proficiency in Microsoft Office Suite, including: Outlook (email communication, scheduling, and coordination with clients and partners). Word (creating documentation, educational materials, and official correspondence). PowerPoint (preparing presentations for internal and external stakeholders).
Experience with electronic enrollment and data tracking systems, such as: TREAT (internal database) and AWARDS, as applicable. eSHARE to support reporting readiness and ensure documentation supports reported services.
Strong documentation and compliance skills, ensuring: Accurate and timely entry of service documentation aligned with contract and funder requirements. Compliance with applicable privacy and data protection requirements, including HIPAA.

Nice To Haves

Experience leading contract-funded or grant-funded programs with defined deliverables, reporting deadlines, and monitoring requirements.
Background working with non-profit agencies, public health programs, or work on behalf of LGBTQ+ communities and/or people living with HIV is highly desirable.
Experience supporting documentation coaching, quality assurance, and performance improvement.
Bachelor’s degree and three years of experience working in Social Work, Human Services, or a related field preferred.

Responsibilities

Conduct comprehensive intakes and assessments to support program enrollment and ongoing service planning.
Support development, monitoring, and updating of individualized care/service plans in coordination with the participant’s care team.
Conduct reassessments at least every six months to evaluate ongoing needs, engagement, and progress toward service plan goals.
Update individualized care/service plans based on reassessment findings within required timeframes.
Assess for duplication of services at intake and on an ongoing basis, and coordinate transitions or service adjustments as needed.
Support participants in gathering required documentation to complete enrollment and recertification, as applicable.
Facilitate referrals and service linkages for participants seeking additional services or supports, in coordination with program workflows.
Coordinate and participate in case conferences with the care team within required timeframes, including initial and ongoing case conferencing to support service coordination and progress toward care plan goals.
Deliver or coordinate required health promotion sessions (individual and/or group) in alignment with program standards.
Provide day-to-day supervision and support to Patient Navigators, including workflow guidance, coaching, and performance feedback.
Monitor documentation practices for accuracy and timeliness, and provide corrective guidance as needed to support program standards.
Participate in team meetings to align roles, coordinate coverage, and strengthen service delivery.
Maintain timely and accurate service documentation and supporting records in the program’s EHR and internal e-chart systems, including TREAT/AWARDS, in accordance with required timeframes.
Ensure service documentation and supporting records are complete and report-ready to support required funder reporting, including data submitted through eSHARE by designated staff.
Enter and update client interactions, enrollment activity, and service delivery documentation in internal systems (for example, TREAT) within required timeframes to meet program and funder documentation standards.
Participate in internal program reviews and data quality checks to support reporting readiness and compliance with funder requirements.
Participate in team meetings, required staff trainings, and collaborative planning to continuously improve service delivery.
Maintain professional standards and comply with agency policies and funder requirements, including confidentiality and documentation expectations.
Collaborate with internal teams and external partners to support participant engagement and coordinated service delivery.
Perform other duties as assigned.