Transition Support Specialist

Community Healthcare Network Inc • New York, NY

3d

About The Position

The Transition Support Specialist will serve as a vital link between persons with justice involvement—particularly those transitioning from carceral facilities in Washington Heights and Long Island City within 90 days into the community−and the Community Healthcare Network (CHN), as well as other community-based social service organizations. Through in-person, tele-video, and telephonic engagement, the Transition Support Specialist will conduct comprehensive assessments of each member’s medical, behavioral, and social needs prior to release (within 90 days) for the purpose of developing a patient-centered plan of care designed to connect members of this special population to appropriate healthcare and social service resources upon reentry into the community. The Transition Support Specialist will provide support, coordination, linkage, and advocacy to justice involved members post release to ensure successful navigation to CHN health centers and community-based referrals that will address their complex medical and social needs with the goal of improving health outcomes and supporting a stable reintegration process.

This position is funded through a two-year grant from the Health Resources and Services Administration (HRSA), spanning from December 1, 2024, through November 30, 2026, to support transitions of care for justice-involved members transitioning/reentering the community.

Requirements

• High School diploma or its satisfactory equivalent.
• Minimum of two (2) years of employment experience, healthcare and/or care management related experience preferred.

Nice To Haves

• Lived experience of the criminal justice system preferred.
• Experience working with special populations, particularly, justice involved preferred
• Bilingual Spanish preferred.

Responsibilities

• Collaborate with Deputy Director and New York State Department of Corrections and Community Supervision (DOCCS) personnel to identify and refer justice involved members scheduled for reentry to NYC communities served by CHN’s health centers.
• Conduct in person initial comprehensive biopsychosocial assessment with participants prior to release from carceral site to determine immediate medical and mental health needs for chronic conditions or self-reports.
• Assessment will be in person prior to release when possible and at the discretion of carceral site personnel.
• Provide Health Education to participants with focus on topics including substance use and overdose prevention, HCV/HIV and other infectious disease prevention, health risk behaviors, medication management/reconciliation, nutrition, and the social support services that can be accessed and set up for the individual prior to release.
• Complete Social Determinants of Health (SDOH) screening and provide appropriate referrals and navigation to address identified needs.
• Develop an initial plan of care (POC) to address immediate needs.
• Schedule, accompany and support justice involved member at initial appointment at one of CHN’s Health Center with 30 days of release from carceral site.
• Complete care conference with care team for justice involved member and update POC to reflect additional goals agreed upon by member and care team.
• Facilitate enrollment into, or reinstate, Medicaid, Veterans Affairs and transportation benefits.
• Refer Health Home eligible members for comprehensive care management/coordination services and for those participants that plan to transition outside of the CHN service area, the Transition Support Specialist will work with the member to identify an accessible health center near their new residence in accordance with established transition of care workflow.
• Manage a caseload of client participants.
• Develop and maintain a collaborative working relationship with CHN and CBOs to facilitate warm handoff referrals for medical, behavioral and social service needs.
• Accompany participants to medical and social services visits, as needed.

Benefits

• Growth and development: Access to various healthcare professionals and benefits to deepen understanding and interest in the various disciplines involved in community health programming.
• Supportive Team culture: Be a part of an interdisciplinary environment where your ideas and work are valued and encouraged.
• Comprehensive benefits: Including health, dental and vision insurance, retirement plans, employee assistance programming and more.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED
• Number of Employees: 101-250 employees