Hospital Outreach Care Coordinator

Bowery Residents Committee • Manhattan, NY

18d • Onsite

About The Position

The Hospital Outreach Care Coordinator coordinates hospital discharge planning and client placements into Safe Haven and other housing settings. The role conducts field-based outreach, supports medically vulnerable clients with healthcare navigation and follow-up care, and maintains documentation and grant reporting to support continuity of care and program compliance.

The position works with hospital social workers, care managers, discharge planners, medical teams, outreach teams, behavioral health providers, shelter staff, and other community partners. It includes hospital visits and travel to outreach locations, Safe Haven programs, and community settings throughout New York City. The coordinator helps clients access appointments, medications, medical equipment, benefits, transportation, and discharge instructions, while identifying concerns and escalating them appropriately.

The role also supports program administration, data collection, quality assurance, grant deliverables, and reporting. It is a full-time, field-based position with working hours of 8:30 a.m. to 5 p.m.; occasional evenings or schedule flexibility may be needed based on hospital discharge coordination and outreach needs.

Requirements

• Medical assistant certification, healthcare training, EMT experience, nursing support experience, or a similar medical background.
• Associate’s or bachelor’s degree, or demonstrated equivalent experience in lieu of a degree.
• Minimum of 1–2 years of experience in homeless services, healthcare coordination, hospital discharge planning, outreach, case management, or a related field.
• Strong interpersonal, communication, and organizational skills.
• Ability to work independently and effectively in office and field settings.
• Proficiency with Microsoft Office and electronic documentation systems.
• Ability to travel throughout New York City, including to hospitals, shelters, Safe Haven programs, and other community locations.

Nice To Haves

• Licensed Practical Nurse (LPN).
• Master of Social Work (MSW).
• Medical Assistant or strong medical assistant experience.
• Experience working with people experiencing homelessness, behavioral health needs, or other vulnerable populations.
• Experience coordinating care with hospitals, healthcare providers, or community-based organizations.
• Knowledge of HIPAA and client confidentiality standards.
• Familiarity with New York City’s homeless services system, healthcare systems, and community resources.
• Experience using trauma-informed, person-centered, and harm reduction approaches.

Responsibilities

• Coordinate discharge planning with hospital social workers, care managers, discharge planners, and medical teams.
• Coordinate patient transfers from hospitals or skilled nursing facilities to Safe Haven programs and other appropriate housing or shelter settings.
• Ensure safe transfers to settings that meet clients’ needs and coordinate the services and staff required for transfers.
• Conduct in-person hospital visits with clients before discharge and support transition planning.
• Collaborate with outreach teams to support continuity of care and engagement after discharge.
• Assist clients with attending medical appointments, obtaining medications and medical equipment, and understanding discharge instructions.
• Monitor and support follow-up care for medically complex and high-vulnerability clients.
• Identify urgent medical, psychiatric, or social service concerns and escalate them appropriately.
• Conduct field-based outreach throughout New York City, including street engagement and visits to hospitals, shelters, and Safe Haven sites.
• Build rapport with people experiencing homelessness using trauma-informed and client-centered approaches.
• Support clients with healthcare navigation, benefits access, transportation coordination, and appointment scheduling.
• Maintain communication with multidisciplinary providers, including hospitals, behavioral health providers, outreach teams, and shelter staff.
• Maintain accurate and timely documentation of client interactions, referrals, placements, and outcomes.
• Track grant deliverables, program metrics, and required reporting data.
• Manage program-related email communication with hospitals, providers, and internal teams.
• Assist with data collection, quality assurance, and grant-related reporting requirements.
• Provide day-to-day administrative support and maintain organized records in compliance with confidentiality and HIPAA-related standards.
• Support program leadership in identifying trends, service gaps, and opportunities to improve coordination.

Benefits

• Competitive health and dental plans, with coverage available for a spouse, domestic partner, and dependents.
• Minimum of 3 weeks of paid vacation, 12 paid holidays, and additional paid sick and personal time.
• 403(b) retirement plan with BRC matching contributions.
• Tuition assistance and career development and training opportunities.
• Flexible Spending Accounts (FSAs) for healthcare, transit, and childcare expenses.
• Free resources for legal, financial, and personal support.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree