Urban Health Plan

Title: Clinical Nutritionist/Registered Dietitian Location: Bronx United States Job ID#: 4430 Job Category: Nutrition Services Position Type: Employee (Full Time) Hybrid Job Description: Position Summary: We are hiring a HYBRID Clinical Nutritionist (RDN/CDN) to join our Nutrition Department. As a Nutritionist, you will be responsible for providing education and counseling to high-risk patients and their families in our primary care and multi-specialty health centers. This particular opening is stationed at our Health center in Bronx, NY with an emphasis on providing support to high risk patients that are being treated through a medical specialist (e.g. Cardiology, GI, Endo, Nephrology). Associate will provide Medical Nutrition Therapy (MNT), education, and behavior change counseling to help improve health outcomes related to chronic disease Minimum Qualifications: - Bachelor Degree or Masters Degree in Nutrition/Dietetics required. - NYS Licensed CDN required- RDN on track for CDN welcomed to apply. - Bilingual Spanish/English required. - Passion for community health. Key Duties: - Assess symptoms, nutrition needs, vitals, labs, Dx, supplement use, allergies, and food access. - Provide MNT, preventative care, education, and nutrition counseling to pt and their families. - Provide appropriate education material, health literate education, and develop a plan. - Schedule and conduct reassessments of patients to f/u on goals and behavior change. - Provide initial and follow-up consultations to patients. - Engage in outreach and therapy to patients with unhealthy weight and chronic illnesses. - Participate in food demonstrations, health fairs, and workshops in collaboration with multi-disciplinary team. - Serve as key member of interdisciplinary team of providers in the care of our patients. Starting Compensation: Minimum $60,000/annum; Maximum $77,000/annum Work Environment Type, Location, and Schedule: Hybrid, Bronx, NY, Monday to Friday 8:00am-5:00pm. 3 days onsite, 2 days remote. As a full time associate at Urban Health Plan, you'll enjoy: - Fully funded Health Insurance for you/ 73.5% funded Health Insurance for your family - Dental, Vision, and Prescription Coverage - 401(k) Retirement Savings (including 3% annual employer contribution) - Comprehensive time off including paid vacation, personal time, sick time, and paid holidays (including your birthday!) - Flex Spending Accounts (Health care, Dependent Care, and Commuter Benefits) - Entertainment Discount Programs - Employee Assistant Program - Eligibility to apply for Public Service Loan Forgiveness Program (PSLF) - Fitness Discounts and Perks through our medical plan. - $50,000 term life Insurance About Urban Health Plan: At Urban Health Plan (UHP) our mission is to continuously improve the health of communities and the quality of life of the people we serve by providing affordable, comprehensive, quality, primary and specialty health care and by assuring the performance and advancement of innovative best practices. At UHP, our commitment to provide patient-centered, holistic, quality health care, is part of a tradition started by our founder, Dr. Richard Izquierdo, more than 50 years ago. That tradition continues today by promoting excellence in everything that we do. UHP is an equal opportunity employer. M/F/D/V. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex, sexual orientation, gender identity, gender expression, national origin/ancestry, citizenship status, disability, age, marital or family status, and military or veteran status. Job Requirements

Provide education and counseling to high-risk patients and their families, deliver Medical Nutrition Therapy, and develop tailored nutrition plans. Engage in outreach and collaborate with interdisciplinary teams to enhance patient health outcomes.

Title: Case Management Supervisor Location: Bronx United States Job ID#: 4396 Job Category: Social Services Position Type: Employee (Full Time) Job Description: Under the guidance of the Senior Director of Social Services, the Case Management Supervisor will assist in the administrative supervision of the day-to-day operations of the Social Services Case Management team. CM Supervisor will ensure that team provides patients with medical support services effectively and in an expedited manner. These services may include the completion of medical forms, letters, and requests for medical information, medical supplies, medical transportation, and emergency resources for UHP patients. Serves as a trainer for new case managers and new processes for existing case managers. Minimum Qualifications: - Bachelor's Degree in Social Work or related field of study required, Master's Degree is preferred. - 3-5 years of direct case management experience in social services, healthcare, or related setting. Preference for previous supervisory experience. - Strong knowledge of community resources. - Excellent communication skills. - Capacity to lead and supervise others - Bilingual English/Spanish required. Key Duties: - Assists with the administrative supervision of the day-to-day operations of the Social Services Case Management team. - Assistant and manage the case manager work flow for all sites, including managing productivity and assignments. - Reviews templates, monitoring continuously and assigning cases to case managers, providing follow up and tracking of patients as assigned to ensure service provision is delivered in a timely manner and address incomplete requests. - Assists case managers in providing emergency referrals to patients dealing with food insecurity, urgent and emergency housing needs, legal support, health insurance assistance, or with any issues causing stress to patient and their families. - Facilitates case management staffing and scheduling, assuring coverage for designated sites in coordination with the site director. - Participates in the development and implementation of new processes for case managers throughout UHP. - Provides training and competency testing of new case managers, ensuring they possess the appropriate qualifications and skills to be a competent and effective case manager. - Facilitates cross training to ensure case management coverage needs are met. - Assists in the completion of annual performance evaluations of supervisees. - Participates in Social Services case management meetings and facilitates case conferencing to achieve best outcome for the provision of case management services for patients. Compensation: $66,300/annum plus benefits. This is a hybrid position requiring both onsite and remote functionality (4 days onsite, 1 day remote); Travel required onsite across UHP health centers, as needed. About Urban Health Plan: At Urban Health Plan (UHP) our mission is to continuously improve the health of communities and the quality of life of the people we serve by providing affordable, comprehensive, quality, primary and specialty health care and by assuring the performance and advancement of innovative best practices. At UHP, our commitment to provide patient-centered, holistic, quality health care, is part of a tradition started by our founder, Dr. Richard Izquierdo, more than 50 years ago. That tradition continues today by promoting excellence in everything that we do. Benefits Include: - Fully funded Health Insurance for yourself - 73.5% funded Health Insurance for your family - Dental Insurance - $50,000 term life Insurance - 401(k) Retirement Savings (including annual UHP Contribution) - Comprehensive time off including paid vacation, personal time, sick time, and paid holidays (including your birthday!). UHP is an equal opportunity employer. M/F/D/V. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex, sexual orientation, gender identity, gender expression, national origin/ancestry, citizenship status, disability, age, marital or family status, and military or veteran status.

Title: Social Worker LMSW (El Nuevo San Juan, Bronx) Location: Bronx United States Job Category: Integrated Care Position Type: Employee (Full Time) Job Description: Position Summary: As a member of our Social Services Department, the Social Worker II/III (LMSW), provides patients with supportive counseling, crisis intervention, psychoeducation, advocacy, and connections to support services. We are seeking Bilingual (English/Spanish) professionals for full time employment based out of our El Nuevo San Juan Health Center. This is a hybrid role - 4 days onsite, 1 day remote. This is a great opportunity for newly licensed LMSWs! You also have capacity to receive clinical hours in this role. Minimum Qualifications: - Master's degree in social work, required. - NYS LMSW Certification, required. - Previous experience and/or training with crisis intervention. - Excellent communication skills. - Dedication to supporting patients in our communities. - Core computer skills including ability to maintain electronic health record. - Bilingual Spanish/English is required. Key Duties: - Conducts psychosocial assessments, provides supportive counseling, complex case management and crisis intervention. - Works closely with the interdisciplinary team to assess and address patients' psychosocial barriers to care. - Refers and connects patients with services including behavioral health treatment, and community-based organizations. - Documents all in-person, and telephone encounters with patients in a timely manner - Maintains patient confidentiality and HIPPA regulations per UHP policy. Starting Compensation: Minimum $67,600 per year; Maximum $75,000 per year Work Environment Type, Location, and Schedule: Hybrid, 1 day remote, Bronx, NY, Monday to Friday 8:00am-5:00pm. As a full time associate at Urban Health Plan, you'll enjoy: - Fully funded Health Insurance for you/ 73.5% funded Health Insurance for your family - Dental, Vision, and Prescription Coverage - 401(k) Retirement Savings (including 3% annual employer contribution) - Comprehensive time off including paid vacation, personal time, sick time, and paid holidays (including your birthday!) - Flex Spending Accounts (Health care, Dependent Care, and Commuter Benefits) - Entertainment Discount Programs - Employee Assistant Program - Eligibility to apply for Public Service Loan Forgiveness Program (PSLF) - Fitness Discounts and Perks through our medical plan. - $50,000 term life Insurance

Title: REMOTE Care Transitions Registered Nurse Location: Bronx, NY Department: Nursing Job ID#: 4351 Job Category: Nursing Position Type: Employee (Full Time) Job Description: Position Summary: The Bilingual English/Spanish Care Transitions Nurse (RN) is responsible for supporting patients during critical transitions of care, particularly following emergency room visits, hospital discharges, and specialty care episodes. This role ensures timely follow-up, medication reconciliation, care coordination, and patient education to reduce readmissions and prevent gaps in care. The Care Transition Nurse works closely with primary care providers, specialists, care management teams, and community partners to ensure continuity of care and improve health outcomes for high-risk and medically complex patients. This role supports the organization's population health, quality improvement, and value-based care initiatives by facilitating safe transitions and promoting patient engagement in ongoing care. As part of the Virtual Care Center- this role is a fully remote position. Although remote, incumbents are required to engage in in person and Bronx-based service throughout training period, and throughout employment for trainings and meetings when requested. Required schedule included Monday through Friday 9am-6pm shift. Minimum Qualifications: - Associates or Bachelors in Nursing is required. - NYS Licensed Registered Nurse is required. - Minimum of 2-5 years of clinical nursing experience is required in ambulatory care, community health, or related setting. - Bilingual Spanish/English is required. - Strong care coordination and patient communication skills - Knowledge of hospital discharge processes and transitional care management - Ability to identify clinical and social determinants of health impacting care - Proficiency in electronic health records and care documentation - Ability to work collaboratively across multidisciplinary teams Key Duties: Transitional Care Management & Patient Follow-Up - Conduct outreach to patients following hospital or emergency department discharge - Complete Transitional Care Management (TCM) workflows in accordance with CMS guidelines - Ensure patients receive timely follow-up appointments with primary care providers or specialists - Facilitate specialty care coordination by assisting patients in navigating referrals, scheduling appointments, and ensuring appropriate follow-up with specialty providers. - Perform medication reconciliation and assess for medication adherence and safety concerns - Identify and address barriers to care, including transportation, social needs, and access issues - Perform medication reconciliation and assess for medication adherence and safety concerns - Identify and address barriers to care, including transportation, social needs, and access issues Care Coordination & Continuity of Care - Coordinate care between hospital systems, primary care providers, specialists, and community resources. - Review discharge summaries and hospital documentation to ensure appropriate follow-up care - Facilitate referrals, diagnostic testing, and specialty appointments as needed - Support patients in understanding discharge instructions and treatment plans Ensure patients do not fall through gaps in care during transitions High-Risk Patient Management - Identify high-risk patients based on clinical, social, and utilization risk factors - Provide additional monitoring and outreach for patients at risk of readmission - Collaborate with care managers, CHWs, behavioral health providers, and social services to address complex patient needs Patient Education & Engagement - Provide patient-centered education regarding diagnosis, medications, warning signs, and follow-up care - Promote patient self-management and adherence to treatment plans - Encourage ongoing engagement with primary care services - Address health literacy and cultural considerations to improve understanding and compliance Data Documentation & Reporting - Document patient encounters and care coordination activities in the EHR - Track outreach efforts, successful contacts, and follow-up outcomes - Support reporting for Transitional Care Management (TCM) billing and quality measures - Contribute to organizational reporting related to readmission reduction and care continuity Quality Improvement & Population Health - Participate in initiatives aimed at reducing avoidable hospitalizations and emergency room utilization - Identify patterns or barriers affecting successful transitions of care - Collaborate with leadership to improve workflows related to discharge follow-up and care coordination - Support quality improvement initiatives related to patient access and care continuity Collaboration & Team Integration - Work closely with providers, care management teams, call center staff, and telehealth teams to coordinate patient care - Communicate patient updates and concerns to primary care teams in a timely manner - Participate in multidisciplinary meetings focused on high-risk patient management and care planning Starting Compensation: Minimum $86,560 per year; Maximum $98,560 per year contingent on degree and years of nursing experience. As a full time associate at Urban Health Plan, you'll enjoy: - Fully funded Health Insurance for you/ 73.5% funded Health Insurance for your family - Dental, Vision, and Prescription Coverage - 401(k) Retirement Savings (including 3% annual employer contribution) - Comprehensive time off including paid vacation, personal time, sick time, and paid holidays (including your birthday!) - Flex Spending Accounts (Health care, Dependent Care, and Commuter Benefits) - Entertainment Discount Programs - Employee Assistant Program - Eligibility to apply for Public Service Loan Forgiveness Program (PSLF) - Fitness Discounts and Perks through our medical plan. - $50,000 term life Insurance About Urban Health Plan: At Urban Health Plan (UHP) our mission is to continuously improve the health of communities and the quality of life of the people we serve by providing affordable, comprehensive, quality, primary and specialty health care and by assuring the performance and advancement of innovative best practices. At UHP, our commitment to provide patient-centered, holistic, quality health care, is part of a tradition started by our founder, Dr. Richard Izquierdo, 50 years ago. That tradition continues today by promoting excellence in everything that we do. UHP is an equal opportunity employer. M/F/D/V. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex, sexual orientation, gender identity, gender expression, national origin/ancestry, citizenship status, disability, age, marital or family status, and military or veteran status.

Provide clinical supervision and guidance to social workers, assist in crisis management and complex cases, and consult on psychosocial issues while ensuring patients' mental health and social service needs are met effectively.

Role Description The Virtual Care Center (VCC) provides rapid access to telehealth appointments for patients with acute medical conditions requiring same-day care. The VCC Medical Assistant is a remote role responsible for managing messages, handling telephone encounters, and assisting the nurse as needed to ensure efficient patient care and communication. Although this is a remote role, incumbents are required to come in monthly to work activities in the Bronx, NY and requires as-needed onsite requirements in New York City. Accordingly, applicants must be in a commutable vicinity to the NYC job market. Qualifications - High School Diploma required. - Previous experience working in a community-based health center or similar setting. - Medical Assistant Certificate or completion of an accredited Medical Assistant program required. - Bilingual Spanish/English required. - 2 years of established Medical Assistant experience. - Flexible work schedule. - Proficiency with computers and software. - Strong communication skills. - Ability to multi-task. Requirements - Assists the call center nurse in ensuring that patients have information required for the scheduled visits. - Provide support during night clinic hours, assisting providers with patient care and administrative tasks. - Assist with post discharge appointments, referrals, DME orders. - Assist with the collection of discharge records, medical histories, and treatment plans. - Perform other job-related duties as required. Benefits - Fully funded Health Insurance for you/73.5% funded Health Insurance for your family. - Dental, Vision, and prescription Coverage. - 401(k) Retirement Savings (including 3% annual employer contribution). - Comprehensive time off including paid vacation, personal time, sick time, and paid holidays (including your birthday!). - Flex Spending Accounts (Health care, Dependent Care, and Commuter Benefits). - Entertainment Discount Programs. - Employee Assistant Programs. - Eligibility to apply for Public Service Loan Forgiveness Program (PSLF). - Fitness Discounts and Perks through our medical plan. - $50,000 term life Insurance.

Review and resolve billing discrepancies, conduct quality assurance checks on documentation, maintain program data trackers, and develop reports to identify trends and performance gaps in a healthcare setting.