Patient Care Coordinator


Date Posted:
Job Code:
57 Willoughby St Lower Level
United States of America



 Position Overview

Patient Care Coordinator will be responsible for overall medical case management services for Primary Care patients.


• Coordinate the completion of intake screening of patients and identify program eligibility to ADHC, OASAS, Health Home, RAD, OMH, PrEP, and other services as identified 

• Coordinates with Intake Specialist to ensure that PRAPARE including PrEP screening for new and annually patient visits 

• Ensure lead is generate in eicare for new patients 

• Assist with completing sliding scale application for uninsured/underinsured patients 

• Coordinate the enrollment of patients into insurance plans including ADAP applications for primary care. 

• Enrollment of patients UND program for any patient identified without connected to PC plus one service.

 • In the absence of the Intake Specialist provides assessment (PRAPARE) and referral services for all clients enrolled in PC, which include but is not limited to, coordination of care and case management referrals 

• Coordinates with care management team for subspecialty and other clinically related referrals made for (All Primary Care clients). 

• Participates in interdisciplinary meetings and transcribe meeting minutes for quality improvement projects. 

• Documents hospitalizations and schedule discharge appointments as needed. 

• Collaborates with OASAS, Health Home, ADHC, Youth and Prevention Services and RAD clinical and support staff to communicate on issues related to clients’ progress and referrals 

• Set up regular on-site meetings with case managers to review status of dually enrolled clients.

 • Documents significant issues that were discussed with regard to client progress. 

• Participates in Morning Huddle, regular medical staff meetings including Quality Improvement. 

• Collaborate with NCC (RN) to create pre-huddle sheets relating to patient needs for provider follow-up 

• Documents clinical interventions in the PC medical records. 

• Coordinates with Ancillary programs such as OMH/ADHC/OASAS to perform client outreach activities.

 • Care coordination ownership unless otherwise designated. 

• Supports and participates in advocacy efforts to end the twin crises of homelessness and AIDS.

 • Assist medical providers with all paperwork needed by clients regarding various needs (i.e. Transportation (2015 Form), Home Health Aide, M 11 Q, HASA, Utilization Threshold, Restriction, Letters, Verifications, etc.) 

• Process paperwork as requested and ensure proper documentation within the EMR. 

• Provide case management programs internal with weekly provider scheduling as well collecting and reporting a list of clients who are no show to appointments at the facility. 

• Monitor patients without case management for Undetectable project, including case conferences and coordination of care. 

• Assist with patient registration process with professionalism and accuracy 

• Performs professional and efficient scheduling of patient appointments 

• Understands the needs of our customers, effectively provides service and or resolves problems, escalate to Clinic Manager or Clinic Director. Dedicated to meeting the expectations of internal and external customers, working to create a positive experience for all 

• Provide coverage for Patient Intake Specialist as needed. 

• Other duties as assigned by either Clinic Director or Clinic Operations Manager. 

• Ability to work occasional evenings and weekends with advance notice 

• Understanding and Practice of the Housing Works Core values of Membership, All In, Stronger Together, Membership and High Performance. 

• Understanding while working in a face pace environment with competing priorities may require assisting in other roles as needed.



Minimum Requirements


Educational Requirements

Bachelor’s Degree preferred. The candidate must have a strong knowledge in HIV/AIDS, case management and entitlements. The candidate should be able to perform psychosocial assessments and reassessment and demonstrate the ability to discern medical emergencies and alert the appropriate medical and clinical personnel for assistance and support. Knowledge of HIPAA regulations on requests for medical documents is required. Strong organizational and clinical skills required, proficiency in Spanish, knowledge of EMR systems is preferred. Candidate must be willing to work on weekends.


Housing Works provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements. Housing Works complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.