Hep C Care Coordinator NYC


Full-time Position: Care Coordinator

Icahn School of Medicine at Mount Sinai

Department of Medicine, Division of Liver Diseases


Project Description:

Project INSPIRE NYC 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. The project will demonstrate that patient-centered medical and behavioral healthcare integrated with care coordination services and telemedicine-based provider training will reduce complications, deaths, and costs from HCV.

The Care Coordinator will provide linkage to care services for patients who are HCV Antibody-positive including and care coordination (Case Management, Education, Outreach, Collaboration, and Logistical Support) to patients with chronic hepatitis C.


  • Navigate HCV Antibody positive patients to on-site viral load/confirmatory testing
  • Follow-up with all HCV Antibody positive patients screened for post-test counseling and basic HCV-related education: natural history, prevention of transmission, evaluation, and treatment
  • Accept and coordinate in house and outside HCV referrals from primary care physicians
  • Schedule patients for all appointments including first on-site HCV evaluation with on-site HCV specialist (within one week), treatment meetings, and follow up appointments on-site and off-site
  • Remind patients one day prior to appointment and check to see if patients adhered to appointment
  • Promote adherence to all HCV-related appointments and send letter and/or telegram for patients lost to follow-up
  • Accompany patients to on-site or off-site appointments when necessary
  • Obtain outside medical records as needed
  • Work closely with on-site HCV primary care champion to ensure patients are engaged with HCV care (e.g. weekly HCV clinics, review case load, and review data requirements)
  • Follow up on labs ordered by the Hepatitis C provider and review results to complete evaluation
  • Check in with patients after appointment with on-site HCV primary care champion for 5-10 minutes:
    1. assess how patient is doing (build rapport)
    2. ask patient to clarify next steps
    3. schedule follow-up appointments in real-time (e.g. ultrasound)
    4. elicit fears and concerns
    5. answer questions
    6. work with any insurance issues and refer to on-site Medicaid office or on-site social worker
  • Prior authorizations for HCV medications, adjuvant medications and other related-procedures
  • Work with Medicaid managed care plans and pharmacies for ordering/delivering HCV-medications
  • Work with pharmacy and provider to dispense medications, assess patient adherence to medications; counsel patients; and review/monitor for drug-drug interactions
  • Provide adherence counseling and assist with side effect management via weekly calls
  • Conduct brief alcohol and mental health screenings and/or interventions
  • Pre-treatment readiness assessments to identify potential barriers to treatment (e.g. using standardized instrument such as PREP-C, reaching out to patient’s primary care provider)
  • Provide HCV education (evaluation, treatment, adherence, and side effect management)
  • Conduct rapid HCV testing at outreach sites and navigate new HCV antibody + patients to center
  • Work with outside labs for uninsured patients in need HCV viral load testing
  • Organize and administer any program incentives (e.g. metro cards)
  • Collect all HCV-related data and input in timely manner within databases
    • Maintain all HCV-related databases (e.g. updating data daily, ensuring data security)
    • Report weekly on database updates to HCV team
  • Provide weekly updates to HCV team meeting for problem solving, QI, future grant applications
  • Attend on-site and off-site trainings as needed.
  • Attend New York City Department of Health HCV Task Force, when possible
  • Work closely with NYC Department of Health (e.g. attend coordinator meetings and data transfer)
  • Attend the weekly Project INSPIRE Mount Sinai HCV telemedicine call
  • Report to Project Director
  • Attend Project INSPIRE meetings
  • Work at multiple clinics in various locations in NYC throughout the week
  • Work closely with community to develop and maintain HCV-related networks (e.g. syringe exchange program and CBOs)
  • Collaborate with HCV team members in dissemination activities (abstracts and papers)
  • Work with and supervise HCV peers navigators – 3-4 per Care Coordinator
  • Provide administrative support to the Project INSPIRE team (e.g. conference room booking; scheduling meetings; updating calendars; and fax machine support)
  • Other duties as needed

Education, Training and Experience:

  • Possess a Bachelor of Science in Public Health, Social Work, Biology, Psychology, Education or an equivalent degree
  • Have at least 4 years of experience in a community health role
  • Must possess knowledge of community resources and health care processes, structure, and function
  • Strongly Preferred bilingual (English and Spanish)
  • Must possess knowledge and experience with personal computers
  • Must demonstrate ability to work effectively in a team environment
  • Must possess the ability to communicate orally and in writing
  • Experience in a supervisory role
  • Demonstrate Independent Judgment


Immediate start date for all four positions.

Two-year commitment expected.

Salary commensurate with experience.


Submit Cover Letter and Resume to:

Ponni Perumalswami, MD, Assistant Professor, Division of  Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai

One Gustave L. Levy Place – Box 1123 – New York, NY 10029

Office: (212) 659-8879– Email: Ponni.Perumalswami@mountsinai.org

Last Updated on December 17, 2017 by HepFree NYC


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