COVID-19 Vaccine available by appointment only, see story on homepage.

Supervisor of Care Coordination - Ryan Health | West 97th Street

January 6, 2021

Position Overview:

Responsible for the management of relationships with outside case management agencies. Provides administrative and clinical supervision of Population Health Patient Navigators and Care Coordinators. Develops and supervises programs designed to address social determinants of health (SDoH) and support patients needing the assistance of care coordination to access necessary medical, behavioral health, and social services. Supervisor oversees these services for all Ryan Network clinic sites and works closely with the site administrative monitors to ensure that the network is compliant with all program expectations and meets quality indicators including productivity. This work is carried out in support of the mission and goals of Ryan Network.

Essential Functions:

  • Act as liaison for outside care management agencies and strengthen relationships with other health homes utilized by Ryan Health patients. Develop and implement workflows to improve communication and referrals between these agencies.
  • Develop registry to track health homes enrolled and eligible patients, including HARP patients; develops workflows to improve Network use of Health Homes, HARP, and other services
  • Monitors productivity and evaluates effectiveness of the internal and external health homes care management programs using objective data to ensure optimal patient care; develop quality improvement plan for the programs
  • Assist with the development and implementation of strategy for addressing Ryan Health population’s social determinants of health; monitor internal use of community resources
  • and SDoH screening tools (I.e. PRAPARE, Aunt Bertha) and complete any reporting needed for funding requirements
  • Create relationships with outside agencies, including mental health providers, drug treatment providers, local social service agencies, and other resources to meet the psycho-social needs of the patients served.
  • Coordinate staff and program activities, including timely and effective management of referrals for concrete services; maintain assignment logs and provide monthly reports on the status of assigned programs/projects/patients.
  • Provide patient navigators and care coordinators with clinical and administrative supervision, identify and support with training needs of staff, and assist with patient care coordination as needed; develop and coordinate in-house Network trainings regarding systems as needed
  • Analyze and report on program-related data and make recommendations for improvement.
  • Assist with program planning, development, and the implementation of programs to address the needs of patients served.
  • Participate in meetings with clinical and administrative staff to monitor progress of program implementation
  • Seek out and attend professional development trainings to keep up to date with relevant evidence- based practices.
  • Serve as a super user for the programs on all systems utilized by program staff to access and document information regarding the patient served and services provided
  • Participate in assessing patients for eligibility for services and reviewing assessments of staff and making clinical recommendations as needed and scope of practice permits.
  • Assist with proposal writing for new programs.
  • Maintain records to documents the supervisory process, meeting minutes, QI activities and clinical work.
  • Other duties and/or projects as assigned.


Minimum Experience and Skills Required:

  • Three years of clinical and administrative experience in the field of Social Work, preferably within a medical setting.
  • Three years of experience working with chronic care populations in a medical setting, including Behavioral Health and HIV populations.
  • Working knowledge of Microsoft Office Suite.

Education, Licenses, and/or Certifications Required:

  • Master’s in Social Work
  • Licensed Medical Social Worker (LMSW)

Preferred Qualifications:

Licensed Clinical Social Worker (LCSW)

Minimal Training Time:

180 actual workdays probationary period.

Competencies Required:

Customer Service:

  • Professional, courteous and respectful attitude in dealing with patients.
  • Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patient served (if applicable).
  • Commits to exceeding expectations of the patient.


  • Works well with others.
  • Contributes input to improve outcomes.
  • Asks others for opinions and feedback; provides feedback in a tactful respectful way;

Working Conditions:

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is frequently required to sit, stand, talk and hear.

The employee is occasionally required to move about the office; use hands and fingers to feel, handle, or operate office equipment.

Specific vision abilities required by this job include close vision and the ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The work is performed primarily in an office setting. The noise level in the work environment may vary.


The duties listed above are intended only as illustrations of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or a logical assignment to the position. This position may be required to perform other duties. If such work becomes a permanent and regular part of the job, a new description will be prepared.

Equal Opportunity Employer

Ryan Health is an Equal Opportunity / Affirmative Action Employer and does not discriminate because of age, color, disability, ethnicity, marital or family status, national origin, race, religion, sex, sexual orientation, gender identity, military veteran status, or any other characteristic protected by law. We are committed to attracting, retaining and maximizing the performance of a diverse and inclusive workforce.

How To Apply