SUMMARY/OBJECTIVE

The Referral Coordinator plays a crucial role in ensuring that patients receive comprehensive and coordinated care by addressing social determinants of health and connecting them with critical support services. The Referral Coordinator works with patients, healthcare providers, and community organizations to facilitate care navigation, resource linkage, and service coordination to improve overall well-being.
The Referral Coordinator is responsible for conducting outreach, identifying social needs, assisting with housing navigation, providing case management, and ensuring Medicaid-eligible individuals receive the necessary support services. The role requires strong interpersonal skills, advocacy, and the ability to develop trusting relationships with patients.
This is a full-time (40 hours per week) position, Monday-Friday or Tuesday-Saturday.
The hourly rate for this position is $22 an hour.
Funding Contingency Statement: This position is part of a new program initiative supported through New York State’s Medicaid 1115 waiver. Employment in this role is contingent upon the continued availability of this specific funding, which is currently anticipated through March 2027. While we are optimistic about the program’s long-term sustainability, the role may be modified or discontinued if funding is reduced or not renewed.

TRAINING & EDUCATION

• Work collaboratively with interdisciplinary teams to promote health equity through culturally competent support.
• Participate in ongoing professional development and trainings related to HRSN services, case management, and trauma-informed care.

QUALIFICATIONS & COMPETENCIES

• High School Diploma required; Associate’s or Bachelor’s degree in human services, public health, or a related field preferred.
• At least 1 year of experience in social services, community health work, or care coordination.
• Experience in housing navigation, case management, or Medicaid programs is highly preferred.
• Strong interpersonal and communication skills, with the ability to build trust with diverse populations.
• Experience working with diverse, low-income, and medically complex families
• Familiarity with Medicaid, Health Homes, or care coordination programs a plus
• Proficiency in Microsoft Office, Excel, and electronic data systems such as EHRs.
• Bilingual (English/Spanish or other language) strongly preferred
• Highly organized, detail-oriented, and committed to health equity and family-centered care
• Proficiency in Microsoft Office (Excel, Word, Outlook) and data entry platforms.
• Bilingual skills preferred (Spanish, Haitian Creole, or another language commonly spoken in NYC communities).

OTHER

• This job description is an overview or major duties, activities and responsibilities required for the role.
• This description is not intended to be a complete listing of all tasks required for the role.
• Responsibilities will change with the needs of the organization.

ESSENTIAL FUNCTIONS

The Referral Coordinator will participate on an interdisciplinary care team to support individuals by addressing their health-related social needs (HRSN) and assisting in service coordination.

• Receive, track, and manage incoming referrals from Social Care Networks (SCNs), community-based organizations (CBOs), hospital partners, and Medicaid members.
• Conduct initial outreach to families to introduce services, explain consent forms, and schedule intake and assessment appointments
• Maintain accurate and up-to-date referral logs and documentation in the organization’s EHR and any required portals, content management systems or referral platforms
• Support the intake and handoff process between Referral Coordinators, Patient Navigators & Community Health Workers.
• Ensure timely communication and documentation with external referral sources regarding referral status and outcomes
• Collaborate with internal teams and external partners to troubleshoot barriers to care coordination and service enrollment
• Attend relevant training, team meetings, and quality improvement sessions related to Medicaid Waiver implementation
• Assist with data collection, reporting, and compliance efforts as required by state and federal guidelines
• Participate in and coordinate community outreach events and canvassing efforts to connect with underserved populations.

REFERRAL & DOCUMENTATION RESPONSIBILITIES

• Coordinate referrals for housing support services, ensuring clients receive assistance with shelter applications and housing stabilization programs.
• Maintain detailed and accurate documentation in electronic health records (EHRs) and referral platforms.
• Track patient progress and follow up on referrals to ensure services were accessed and outcomes achieved.
• Assist with data collection and reporting for Medicaid Waiver initiatives and contracted programs.
• Support program compliance by adhering to contractual obligations for PHS HRSN services, including tracking performance metrics.

The work environment characteristics described herein are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• This job operates in an office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.
• The office for this job is located in the same facility where RMH-NY provides temporary accommodations to pediatric patients and their families while the patients are undergoing active medical treatment at area hospitals. For some RMH-NY guests, medical treatment may include radiation therapy. While radiation therapy is never administered at RMH-NY, there is the potential for some radioactive material to be present in guests who have undergone radiation therapy. Based on radiation measurements performed throughout RMH-NY, it is not expected that individuals working at RMH will receive radiation doses that would exceed the general public limit (100 millirem per year).
• The noise level in the work environment is moderate to loud. Noise levels often increase with families and children who have temporary residence in the building as well as guests and musical performers for special events.
• This position requires flexible schedule at times to meet the needs of the families. Some weekends and evening hours are necessary