Hep C Care Coordinator

Project Description:

Project InspireProject INSPIRE 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. The project will utilize care coordination to assist medical providers in improving overall outcomes related to treatment while reducing psychosocial and behavioral barriers to care.

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, inform quality improvement
  • Attend on-site and off-site trainings as needed.
  • Attend New York City Department of Health HCV Task Force, when possible
  • 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)
  • Other duties as needed

Education Training and Experience:

  • Possess a Bachelor of Science in Public Health, 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
  • 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. One-year commitment expected. Salary commensurate with experience.


Submit Cover Letter and Resume to:

Brooke E. Wyatt, MPH

Project Director
Division of Liver Diseases
Icahn School of Medicine at Mount Sinai
1255 Fifth Avenue, Suite C1
New York, NY 10029-6574
O: 212-824-9727 | F: 212-824-9740




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