Patient Care Coordinator


Date Posted:
Job Code:
2626-2640 Pitkin Ave
United States of America
Administrative and Support



Position Overview

Patient Care Coordinator (PCC) is responsible for screening patients’ social determinants of health and helping determine best ways to ensure they are met by referring to other programs and services as needed. The PCC advocates for patients’ best interests and helps ensure that the services outlined in their clinical pathway plan are provided.


1. Provide coverage for Patient PRAPARE. 

2. Along with the Intake Specialist, conduct PRAPARE assessment for all clients enrolled in primary care and behavioral health, and facilitate overall coordination of care as well as provide case management referrals.

3. Coordinate with other care management teams both internally and externally, to help patient meet their care plan goals.

4. Facilitate communication with OASAS, Health Home, ADHC, Youth and Prevention Services, RAD and other clinical and support staff on issues related to clients’ progress, referrals, and outreach needs.

5. Facilitate enrollment of patients in the Undetectables (UND) program.

6. Facilitate medical records requests and ensure completion within timeline outlined in policies.

7. Ensure UND patients remain in good standing (eg renewals, up to date labs, etc).

8. Participate in interdisciplinary meetings and transcribe meeting minutes for quality improvement projects as needed.

9. Oversee or directly facilitate documentation of hospitalizations and discharge follow-up appointments as needed.

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

11. Document significant issues discussed with regard to client progress.

12. Participate in daily Huddle, regular staff meetings including but not limited to Quality Improvement, etc.

13. Collaborate with Nurse Care Coordinator to create huddle sheets relating to patient needs for provider follow-up.

14. Document clinical and administrative interventions in the medical records.

15. Ensure care coordination ownership unless otherwise indicated.

16. Support and participate in advocacy efforts to end the twin crises of homelessness and AIDS.

17. Assist providers with paperwork needed by clients regarding various needs (i.e. Transportation, Home Health Aide, M11Q, HASA, Utilization Threshold, Restriction, Letters, Verifications, etc).

18. Process paperwork as requested and ensure proper documentation within the medical record.

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

20. Work with programs on scheduling case conference meetings with providers, and do same for clients who do not belong to internal case management program.

21. Conduct or oversee patient outreach especially for those who have been lost to follow and must be reengaged.

22. Understand the needs of customers, effectively provide service and or resolve problems, and escalate to Clinic Director as needed.

23. Ensure dedication to meeting the expectations of internal and external customers, working to create a positive experience for all.

24. Coordinate the enrollment of patients into the UND program as needed.

25. Complete documentation regarding client assessments, consent forms, and demographic and contact information.

26. Other duties as assigned.

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

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

Job Requirements:
Educational Requirements

Associate’s Degree, or higher, required.
One to two years of previous experience in a medical setting or related field preferred.
Must have experience with Microsoft Office (Word, Excel), Outlook, and the Internet.

Minimum Requirements


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. Housing Works also does not request prior salary information during the hiring process. 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.

This position is included in a bargaining unit of Housing Works’ New York City employees represented by a labor union known as the Retail Wholesale and Department Store Union (“RWDSU”).  Accordingly, the RWDSU has the exclusive right to bargain over the terms and conditions of employment related to this position and this position may become covered by the terms of a collective bargaining agreement (a “CBA”) between Housing Works and the RWDSU. 

Housing Works is a healing community of people living with and affected by HIV/AIDS. Our mission is to end the dual crises of homelessness and AIDS through relentless advocacy, the provision of lifesaving services, and entrepreneurial businesses that sustain our efforts.