Description Palliative Care at Home provides home based palliative symptom assessment, treatment and ongoing goals of care discussions for patients and families facing advanced illness. The full clinical team is comprosed of CHWs, NPs, nurses, social workers and physicians. The team works in collaboration with patients' healthcare teams to provide high quality evidence based complex palliative care and chronic care management and is designed to improve symptoms and QOL, reduce caregiver burden, reduce unnecessary inpatient utilization, and facilitate hospice when appropriate. Responsibilities

DESCRIPTION OF COMPETENCIES A.

Operational Duties

• Serve as a link between health and social care services and community to improve access to palliative care and quality of care
• Works as a member of our interdisciplinary care team assessing and addressing the complex care needs of patients and families
• Develop understanding of the patient and caregivers illness understanding and health literacy
• Follow up on goals of care discussions and ensure care plans consider culture and health literacy
• Monitor patient and caregiver needs
• Work closely with interdisciplinary team to address changes in patient needs or symptoms
• Coordinate patient care including but not limited to scheduling appointments, follow up after hospital/ED
• Educates patient/family on trajectory of illness, use of medications, assesses disease understanding
• Facilitate virtual visits with providers or nursing visits as needed
• Promote personal empowerment and engagement in health, including help navigating healthcare system
• Participate in weekly IDT meeting with care team
• Monitors care plans in conjunction with the rest of the clinical care team
• Documentation as required
• Performs other related duties as assigned B. Knowledge Skills and Abilities
• Excellent communication skills and ability to connect with patients and caregivers
• Competence in utilizaing multiple software applications on computer and mobile devices
• Compassionate with desire to improve care for seriously ill individuals and families
• Exhibits professionalism patients with staff, patients, caregivers
• Working knowledge of medical terminology and healthcare system
• Ability to act as effective advocate for patients and caregivers, ability to work in emotionally charged situations

Qualifications Required:

• High School diploma or equivalent
• 2+ years of experience working with patients in home care environment
• Experience and comfort working in home settings with patients and families, including difficult living conditions or environments
• Experience working in interdisciplinary teams

Preferred:

• Certified home health care worker
• Health coaching certification
• Palliative/hospice experience
• Spanish speaking proficiency/fluency Employer Description Strength through Unity and Inclusion The Mount Sinai Health System is committed to fostering an environment where everyone can contribute to excellence.

We share a common dedication to delivering outstanding patient care. When you join us, you become part of Mount Sinai's unparalleled legacy of achievement, education, and innovation as we work together to transform healthcare. We encourage all team members to actively participate in creating a culture that ensures fair access to opportunities, promotes inclusive practices, and supports the success of every individual. At Mount Sinai, our leaders are committed to fostering a workplace where all employees feel valued, respected, and empowered to grow. We strive to create an environment where collaboration, fairness, and continuous learning drive positive change, improving the well-being of our staff, patients, and organization. Our leaders are expected to challenge outdated practices, promote a culture of respect, and work toward meaningful improvements that enhance patient care and workplace experiences. We are dedicated to building a supportive and welcoming environment where everyone has the opportunity to thrive and advance professionally. Explore this opportunity and be part of the next chapter in our history. About the

Mount Sinai Health System:

Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 48,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time — discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients' medical and emotional needs at the center of all treatment. The Health System includes more than 9,000 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics, top 5 in Cardiology/Heart Surgery, and top 20 in Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report's "Best Children's Hospitals" ranks Mount Sinai Kravis Children's Hospital among the country's best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 11 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek's "The World's Best Smart Hospitals" ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally. Equal Opportunity Employer The Mount Sinai Health System is an equal opportunity employer, complying with all applicable federal civil rights laws. We do not discriminate, exclude, or treat individuals differently based on race, color, national origin, age, religion, disability, sex, sexual orientation, gender, veteran status, or any other characteristic protected by law. We are deeply committed to fostering an environment where all faculty, staff, students, trainees, patients, visitors, and the communities we serve feel respected and supported. Our goal is to create a healthcare and learning institution that actively works to remove barriers, address challenges, and promote fairness in all aspects of our organization. Compensation The Mount Sinai Health System (MSHS) provides salary ranges that comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $27.8466 - $41.7699 Hourly. Actual salaries depend on a variety of factors, including experience, education, and operational need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.

Qualifications:

Required:

• High School diploma or equivalent
• 2+ years of experience working with patients in home care environment
• Experience and comfort working in home settings with patients and families, including difficult living conditions or environments
• Experience working in interdisciplinary teams

Preferred:

• Certified home health care worker
• Health coaching certification
• Palliative/hospice experience
• Spanish speaking proficiency/fluency