Care Coordinator - Affordable Housing Program

Oneida Healthcare - Oneida, NY (30+ days ago)3.4

Oneida Healthcare (OHC) is a 101-bed acute care hospital and a 160-bed extended-care facility (ECF) and short-term rehab facility licensed by the State of New York and operated by Oneida Health Systems, Inc., a New York not-for-profit corporation. The hospital is Joint Commission accredited.

OHC is proud to announce that we have recently been recognized for several national awards based upon safety of care as well as the patient experience of care. The first recognition is provided by The Leapfrog Group, a nationally recognized non-profit organization who reviews 30 patient quality and safety measures and assigns a letter grade to over 2,600 hospitals nationally based upon outcomes. The 2018 spring letter grade for OHC is an “A.”, our fourth consecutive “A” with OHC as one of only 8 in New York to achieve an "A" for Spring 2018. The second recognition is for the Healthgrades Outstanding Patient Experience Award. Our hospital is in the top 10% nationally for patient experience as recognized by Healthgrades and is one of only 8 hospitals in New York to receive this award for 2017. The third recognition is the Women's Choice Award, our second consecutive award for patient experience as a top 100 hospital. All of these awards are based, in part, on our CMS 4-Star rating for patient experience.

Oneida Healthcare provides a Care Coordinator onsite for 10 of the units at the Seneca Fields apartments to provide oversight of tenants that have gained their apartment because of their risk for decline without that service.

  • The duties would include but are not limited to:
  • Assessment of the residents’ needs and development of a health care plan.
  • Oversite of the tenants compliance with their health care plan,
  • The coordinator will serve as the resident advocate to ensure an optimal level of functioning is maintained and will provide referrals to community agencies as needs arise.
  • The coordinator will also be responsible for seeing that a safety assessment has been performed on admission and annually.

In an effort to assist with the assessment of resident needs, the care coordinator would be part of the tenant’s medical team. In this capacity the coordinator will share pertinent information to the tenant and may serve as a conduit of information to their physician’s office or other medical or wellness related services. The Care Coordinator will offer insight into daily functioning, and be aware of the health care goals and changes and or decline or improvement and effectively communicate this to the tenant or other pertinent individuals. (eg, education on diabetic testing, medication management (which may include set-up of meds 1x per week) understanding rehab services and following exercise programs when applicable, oxygen use, etc.)

As a referral source the coordinator would discuss with the resident, family, and healthcare providers various community services available to the resident. The coordinator would also arrange for medical and wellness appointments and transportation and monitor follow through with the referral agencies.

The Care Coordinator will see that a safety assessment is done on admission and annually to ensure the safety of the resident. A SMART care plan will be maintained and updated every 30 days. The coordinator will advocate for the resident to ensure an optimal level of functioning is sustained and success in meeting their health care goals is achieved.

The Care Coordinator will also work with the Affordable Housing Management and ECF Administrator to articulate change in condition or non-compliance that may indicate temporary or permanent change in the individual’s ability to continue living in the apartment.

The program is grant based and will require completion of online reports (both narrative and data) on a monthly or quarterly basis (as dictated by the Grant).

The ideal Care Coordinator will be a graduate from an RN program and able to operate and act independently. Candidate must have strong interpersonal skills and be able to clearly communicate verbally and in writing.

Compensation / Benefits

Competitive salary and excellent benefits, including 403(b) with both matching and discretionary contributions, generous health insurance benefits, paid life/LTD insurance and 29 paid days off to start.

Job Type: Full-time


  • RN: 1 year