Care Coordination Liaison

MetroPlusHealth; New York (NY); On-site; USD 65,000 - 95,000; Full time

Job summary

MetroPlusHealth in New York is seeking a Care Coordination Liaison to strengthen links with NYC Health + Hospitals and improve transitions of care. The role focuses on inpatient and post-acute care, coordinating with care management teams, providers, and care teams to support members through transitions and connect them with community resources.

You will work across inpatient and post-acute settings, coordinating with care management teams, H+H providers, and member care teams, emphasizing

Qualifications

• Master’s degree in social work or related field.
• LMSW or LCSW license in NY required.
• Minimum two years of care management experience.

Responsibilities

• Facilitates bidirectional communication between H+H providers and MetroPlusHealth care teams via email and Epic in-basket.
• Supports care transitions across settings, coordinating with inpatient, ED, rehab, home health.
• Ensures timely appointment scheduling and discharge summary integration in EPIC.
• Outreaches to at-risk members for readmission prevention and care coordination needs.
• Maintains accurate documentation in care management systems per standards.

Skills

Care coordination

Communication

Time management

Problem solving

Interpersonal skills

Education

Master’s Degree

LMSW or LCSW license

Tools

Epic EHR

Microsoft Office

Job description

Empower. Unite. Care.

MetroPlus

Empower. Unite. Care. MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

About NYC Health + Hospitals

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers.

Position Overview

The Care Coordination Liaison strengthens coordination between MetroPlusHealth and NYC Health + Hospitals (H+H) to improve care coordination, remove systemic barriers, and support better outcomes for H+H-attributed MetroPlusHealth members.

This role focuses primarily on inpatient and post-acute transitions of care, with an emphasis on timely information exchange, proactive member outreach, and coordination across MetroPlusHealth Care Management teams, H+H providers, contact center teams, and care teams. The Care Coordination Liaison supports care teams and members through targeted interventions, especially for H+H-attributed Medicare/MAP members hospitalized at non-H+H facilities.

Under the direction of the Senior Director of Integrated Care Management, the Care Coordination Liaison is a member of a team that provides care coordination services to our MetroPlusHealth members wo are attributed to and receiving care at NYC Health + Hospitals (H+H) to improve quality of care, collaboration and communication between the systema and the health plan. The Care Coordination Liaison will engage with the member and the member’s care team to improve their health and connect to community resources that will support their well-being to ensure quality outcomes (i.e., reduction in emergency room visits and hospital admissions, improved member satisfaction, closing and reducing Gaps in Care) and cost effectiveness.

Work Shifts

9:00 AM - 5:00 PM

Duties & Responsibilities

• Facilitates bidirectional communication between H+H providers and MetroPlusHealth Care Management teams primarily by email and Epic in-basket, triaging issues and inquiries and providing timely responses to messages to rapidly resolve challenging care management issues.
• Supports care transitions across settings, including emergency department, inpatient, skilled nursing/rehab, home health, and extramural facilities by serving as a designated point of contact to ensure communication is focused and appropriately directed.
• Ensures continuity of care through timely appointment scheduling; integration of discharge summaries into EPIC; provider and/or member/caregiver notifications, outreaches and follow ups, primarily using Epic messaging; and escalates untimely appointment access as needed
• Conducts targeted outreach to select members at risk of readmission and those requiring assistance with appointments, transportation, Durable Medical Equipment (DME), medication, social drivers of health, and related care coordination needs.
• Collaborates with care management leadership and multidisciplinary teams to identify and track recurring complex care management challenges and systemic barriers, especially those that require coordination across teams; support cross-organizational solutions that can improve patient/ member outcomes.
• Maintains accurate, comprehensive, and current clinical and non-clinical documentation in the care management system, Epic and/or other applicable systems in accordance with professional standards, regulatory guidelines, and departmental expectations.
• Participates in interdisciplinary rounds and meetings to coordinate member care as needed.
• Provides support to MetroPlusHealth departments regarding member retention, utilization management, quality management, customer service, provider relations, and other member-related concerns as needed.
• Comply with orientation requirements, annual and mandatory training, organizational and departmental policies and procedures, and actively participate in the evaluation process.
• Participate in special projects, including audit preparation, quality improvement, community health education, facility/provider relations, marketing activities, facility visits, community events, home visits, and community meetings as assigned.
• Ensuring work is consistent with applicable Federal, State, and City regulations and with the Mission, Vision, and Values of the organization.
• As needed, will travel within the MetroPlusHealth service area to support facility visits, community events, home visits, community meetings, and professional conferences.
• Performs other duties as assigned by Leadership.

Minimum Qualifications

• Master’s Degree required.
• A minimum of two years of care management/coordination, health education, health home or community-based experience required. Managed Care experience is preferred.
• Proficiency with computers, including navigation across multiple systems and web-based applications, is required.
• Must know how to use Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook.
• Ability to proficiently read and interpret medical records, claims data, pharmacy information, lab reports, and prescriptions is required.

Licensure And/or Certification Required

• A valid license and current registration to practice as a Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW) issued by the New York State Education Department (NYSED).

Professional Competencies

• Confident, autonomous, solution-driven, detail-oriented, nonjudgmental, diplomatic, resourceful, resilient, proactive, and committed to high standards of excellence.
• Strong verbal and written communication skills, including motivational coaching, influencing, negotiation, engagement, and relationship-building abilities.
• Strong time management, organizational, prioritization, problem-solving, critical thinking, and judgment skills, including the ability to manage changing priorities under pressure.
• Ability to work closely with members/caregivers and form effective working relationships with providers, interdisciplinary teams, community partners, and a wide range of individuals.
• Ability to identify trends, elevate issues, and support cross-organizational solutions.
• Functional/technical skills related to care coordination workflows, systems navigation, clinical documentation, and data-informed tracking/trending

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