• Perform screenings, education, and navigation for health-related social needs
• Document care coordination services and referrals in a timely and accurate manner, in the patient electronic health record (EHR) and any other platforms (e.g. Unite Us) as requested
• Assist patients with transportation needs to support timely and safe discharges and continuity of care at follow up appointments
• Coordinate/schedule follow up appointments for patients to support transition of care goals
• Conduct patient phone outreach post-discharge to support transitions of care
• Facilitate referrals of patients to Wyckoff programs that can support the patient’s treatment goals and/or social needs
• Provide support and facilitate access to resources to ED-based programs such as the Opioid Overdose Prevention Program
• Maintain a tracker of services provided and patients who were assisted, and provide regular reports and summaries as requested by supervisor and the 1115 Waiver leadership team
• Collaborate with other departments (e.g. Social Work, Population Health) to address patient needs holistically and comprehensively
• Demonstrate excellent customer service, professionalism, and sensitivity toward patients and coworkers
• Participate in regular huddles and interdisciplinary team meetings
• Attend trainings and orientations as required, including virtual, on-site and off-site
• Other related duties as assigned

   Formal Education  and Job-Related Experience. High School Diploma/GED.  Experience working with electronic health records (EHRs) preferred.

Salary - $55,000 Annually