Position: Hepatitis C Care Coordinator

*Must be able to travel to multiple clinics in various locations in New York City throughout the week. This is a full-time position with benefits. During COVID-19, role is partially on-site in clinic and partially remote. May return to fully onsite/clinic in future.

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Program Background

LEAP (Liver Education & Action Program) at Mount Sinai aims to improve the treatment of hepatitis C (HCV) infection in NYC. It is estimated that 146,500 NYC adults (2.4% of the NYC population) have chronic HCV infection, which causes cirrhosis, end-stage liver disease, liver cancer, and death in 20% of infected persons. LEAP utilizes comprehensive care coordination to assist medical providers in improving overall outcomes related to treatment while reducing psychosocial and behavioral barriers to care.

Role Responsibilities

The Care Coordinator will provide case management, education, outreach, collaboration, and logistical support to patients with chronic hepatitis C as they navigate the HCV treatment process. Including:

  • Develop effective relationships with patients and their caregivers as well as the medical team to promote interdisciplinary communication, continuity of care, and adherence to patients’ care plans. Provide a central point of contact and escalate concerns appropriately.
  • Collect all HCV-related data and input in a timely manner into RedCap database (updating data daily, ensuring data security and accuracy); document encounters in electronic medical record (EPIC).
  • Promote and monitor appointment adherence with follow-up calls and letters
  • Conduct brief alcohol, substance use, and mental health screenings and/or interventions
  • Administer pre-treatment readiness assessments to identify potential barriers to treatment (e.g. using standardized instrument such as PREP-C).
  • Provide patient education on the natural history of HCV, prevention of transmission, evaluation, treatment, adherence, and side effect management, as well as general healthy living, alcohol, and substance use
  • Provide patients with referrals to internal and community resources, including primary care providers, social services, mental health and substance use resources, etc.
  • In clinic, check in with patients after appointments with liver provider:
  • assess how patient is doing (build rapport)
  • ask patient to clarify next steps
  • schedule follow-up appointments in real-time (e.g. ultrasound)
  • elicit fears and concerns
  • answer questions
  • work with any insurance issues and refer to on-site finance office
  • Work with pharmacies and providers to prepare prior authorizations for medications, order/deliver/dispense medications
  • Provide adherence counseling and monitor patient-reported side-effects via weekly calls, and report to provider as needed
  • Accept and coordinate in-house and outside HCV referrals from liver providers, primary care physicians, and the LEAP linkage to care team
  • Assist linkage to care team by outreaching previously screened HCV-positive patients who have not been treated
  • Schedule patients for all appointments including first on-site HCV evaluation with on-site HCV specialist, treatment meetings, and follow-up appointments on-site and off-site
  • Accompany patients to on-site or off-site appointments when necessary
  • Obtain outside medical records as needed
  • Follow up on labs ordered by the HCV provider and review results
  • Organize and administer any program incentives (e.g. metro cards)
  • Report to and meet with Program Manager at least monthly
  • Meet with and report directly to Senior Care Coordinator one-on-one
  • weekly to case conference and go over any logistical concerns
  • monthly to review data and case load
  • Attend team meetings and contribute to case presentations; participate in group case conferences, problem-solving, and process improvement discussions
  • Attend on-site and off-site trainings as assigned
  • Work with community partners to develop and maintain HCV-related networks (e.g. syringe exchange program and CBOs). Foster relationships with outside organizations to facilitate warm handoffs.
  • Other duties as they arise

Required Education and Experience

  • Master’s degree in relevant field (e.g., Public Health)
  • At least 1-2 years of experience in community health, case management, health education, or related field
  • Knowledge of community resources and health care processes & structures
  • Preferred bilingual (English and Spanish)
  • Knowledge and experience with personal computers, especially Microsoft Office Suite (Excel, Outlook, Word, PowerPoint), databases (e.g., Access or RedCap), and electronic medical records (e.g., EPIC)
  • Ability to function at high level remotely (i.e. from home via Zoom, phone, text, etc.) on days not in clinic
  • Strong interpersonal and teamwork skills
  • Excellent oral and written communication skills and attention to detail
  • Strong independent judgment, problem-solving skills, and ability to thrive in a rapidly evolving environment
  • Eagerness to take on new tasks

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