Hospital Outreach Care Coordinator

Role Overview
​The Hospital and Care Coordination position is responsible for coordinating hospital discharge planning, facilitating client placements into Safe Haven and other housing settings, conducting field-based outreach, supporting medically vulnerable clients through healthcare navigation and follow-up care, and maintaining accurate documentation and grant reporting to ensure continuity of care and program compliance.​

Key Responsibilities

​​Hospital and Care Coordination

​Coordinate discharge planning with hospital social workers, care managers, discharge planners, and medical teams.
​Coordinate the movement of patients between a hospital or skilled nursing facility and Safe Haven programs and other appropriate housing or shelter settings.
​Ensure a safe transfer to a setting that meets the patient's needs and coordinates necessary services and staff required to complete the transfer.
​Conduct in-person hospital visits to meet with clients prior to discharge and support transition planning.
​Collaborate closely with outreach teams to ensure continuity of care and engagement after discharge.
​Assist clients in attending medical appointments, obtaining medications, securing 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 appropriately.

​Outreach and Client Engagement

​Conduct field-based outreach throughout New York City, including street engagement and visits to hospitals, shelters, and Safe Haven sites.
​Build rapport with individuals 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.

​Administrative and Grant Management Duties

​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 reporting requirements related to grant funding.
​Provide day-to-day administrative support, maintain organized records while ensuring compliance with confidentiality and HIPAA-related standards.
​Support program leadership in identifying trends, service gaps, and opportunities for improved coordination.​

Required Qualifications

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

Preferred Qualifications

​​Licensed Practical Nurse (LPN).
​Master of Social Work (MSW).
​Medical Assistant or candidates with strong medical assistant experience.
​Experience working with individuals 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.​