Bridge to Home Referral Coordinator

NYC Health + Hospitals

New York

NY

Remote

$

95713

$

95713

/HR

/year

CREDENTIAL/LICENSE REQ:  
LCSW
Offers Clinical Hours

AGENCY Description

The Critical Operations & Response (COR) unit will provide support for high-priority and/or emergency initiatives. This unit will fill a gap for NYC Health + Hospitals and the City of New York in a sustainable way that will allow for more comprehensive, efficient, and timely responses to urgent needs. Specifically, the COR Unit will be positioned to respond to future emergencies that must be sustained longer than a traditional emergency response but are not intended to continue indefinitely. The COR Unit will also support critical operations within H+H such as Bridge to Home (BTH) between activations as a way to expand the overall operational infrastructure and drive forward new initiatives. BTH is a new innovative program developed by NYC Health + Hospitals that will provide treatment, social and professional skill building, and temporary housing to patients with serious mental illness (SMI) who are ready for discharge from the hospital but do not have immediate access to stable housing.

Job Description

The Critical Operations & Response (COR) unit will provide support for high-priority and/or emergency initiatives. This unit will fill a gap for NYC Health + Hospitals and the City of New York in a sustainable way that will allow for more comprehensive, efficient, and timely responses to urgent needs. Specifically, the COR Unit will be positioned to respond to future emergencies that must be sustained longer than a traditional emergency response but are not intended to continue indefinitely. The COR Unit will also support critical operations within H+H such as Bridge to Home (BTH) between activations as a way to expand the overall operational infrastructure and drive forward new initiatives. BTH is a new innovative program developed by NYC Health + Hospitals that will provide treatment, social and professional skill building, and temporary housing to patients with serious mental illness (SMI) who are ready for discharge from the hospital but do not have immediate access to stable housing.

Job Responsibilities

The Referral Lead will primarily support the BTH program day-to-day but will also support larger COR initiatives such as Special Medical Needs Shelters (SMNS) and Hotel Quarantine Isolation Program (HQIP) and other projects as they arise. The Referral Lead will report to the Executive Director of COR. The referral lead will report to the Senior Assistant Vice President of COR and have a dotted line to the Office of Behavioral Health Complex Needs team for clinical support.

• Develop standard workflow for reviewing and accessing incoming referrals to the BTH program

• Interview potential guest for the program to see if they are interested and suitable for the program

• Work closely with the BTH local Site Directors to understand the differences in site capabilities in order to better triage referrals to sites

• Liaise with referring staff from NYC Health + Hospitals facilities including: Inpatient Psych, Expended Care Unit, Correctional Health, Safety-net and PORT clinics to develop a continuous pipeline of referred patients and actively maintain waiting list

• Run regular in-service trainings with BTH Site Directors and Psychiatrists to help facility staff better understand the program and what will make a successful candidate

• Support Epic referral enhancements as needed

• Work with the COR team, to build out preparedness models to support future citywide or tactical activations, including, but not limited to Special Medical Needs Shelters and Hotel Quarantine Isolation Program

• Support coordination as needed with hospitals, long-term care facilities, ambulatory sites, shelters of all kinds, and community partners during emergencies to ensure continuity of care

• Other duties as assigned

Job Qualifications

Valid license as an LCSW issued by the NYSED


Experience working with patients with SMI preferred


Experience working with patients with housing instability preferred


Experience working with Epic preferred

Job Benefits, Training, and Opportunities

NYC Health and Hospitals offers a competitive benefits package that includes:

  • Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
  • Retirement Savings and Pension Plans
  • Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
  • Loan Forgiveness Programs for eligible employees
  • College tuition discounts and professional development opportunities
  • College Savings Program 
  • Union Benefits for eligible titles 
  • Multiple employee discounts programs
  • Commuter Benefits Programs