Transition Support Specialist at Community Healthcare Network Inc

New York, New York, United States -

Full Time

Start Date

Immediate

Expiry Date

21 Jun, 26

Salary

60161.0

Posted On

23 Mar, 26

Experience

0 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Case Management, Care Coordination, Needs Assessment, Advocacy, Medication Management, Health Education, Social Determinants Of Health Screening, Benefit Enrollment, Interdisciplinary Collaboration, Caseload Management, Community Resource Linkage, Reintegration Support

Industry

Hospitals and Health Care

Description

WHO WE ARE: Community Healthcare Network (CHN) is a not-for-profit organization providing more than 65,000 New Yorkers with primary and behavioral healthcare, dental, nutrition, wellness, and needed support services. Our network is made up of 14 federally qualified health centers throughout Brooklyn, the Bronx, Queens, and Manhattan, along with a fleet of mobile vans that bring health services to underserved people in need throughout New York City. We provide judgment-free, high-quality healthcare, without regard to race, religion, orientation, gender identity, immigration status or ability to pay. We turn no one away. WHAT WE OFFER: 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. POSITION SUMMARY: 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. DUTIES AND RESPONSIBILITIES: Essential Functions: * 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. EDUCATION & EXPERIENCE REQUIRED: * High School diploma or its satisfactory equivalent. * Minimum of two (2) years of employment experience, healthcare and/or care management related experience preferred. * Lived experience of the criminal justice system preferred. * Experience working with special populations, particularly, justice involved preferred * Bilingual Spanish preferred.

Responsibilities

The specialist acts as a link between justice-involved individuals transitioning from carceral facilities and healthcare/social service organizations, conducting comprehensive needs assessments before and after release to develop patient-centered care plans. They provide support, coordination, linkage, and advocacy post-release to ensure successful navigation to appropriate resources to improve health outcomes and support stable reintegration.