Care Coordination Specialist for High-Risk Patients

Northwell Health; Manhasset (NY); On-site; USD 55,000 - 75,000; Full time

Job summary

Northwell Health in New York is seeking a Care Management professional to coordinate services for families and caregivers. The role involves building rapport through motivational interviewing and developing individualized care plans for high-risk patients enrolled in Health Home Plus.

You will work with hospitals, PCPs, specialists, and community resources to ensure seamless care coordination, track at-risk groups, and perform outreach in various settings to improve follow-up and access to

Qualifications

• High School Diploma or equivalent required.
• 1-3 years of relevant experience, required.
• Bachelor's or Master's degree in relevant field strongly preferred.
• A CASAC credential and two years of experience; OR a Bachelor's degree with three years of experience as a Health Home care manager serving the SMI/SED population is highly preferred.
• NYS Driver's License strongly preferred.

Responsibilities

• Coordinates and participates in activities related to Care Management services to family members and caregivers.
• Participates in development, maintenance, and adjustment of individualized care plans for high-risk patients addressing medical and social barriers to accessing care.
• Acts as a professional liaison between hospitals, primary care providers, specialists, and community resources to ensure patient-centered care coordination.
• Identifies and tracks special populations, including high-risk patients and others due for preventive or chronic care services.
• Identifies and tracks patients discharged from inpatient services or the emergency department.
• Uses team-based communication strategies to close the loop on referrals and hospital follow-ups, performing outreach in primary care sites, homes, hospitals, and neighborhoods.

Skills

Motivational interviewing

Care coordination

Panel management

Care planning

Team communication

High-risk patient support

Education

High School Diploma

Bachelor's degree preferred

Master's degree preferred

CASAC credential

NY Driver's License preferred

Tools

EHR systems

Job description

Northwell Health in New York is seeking a Care Management professional to coordinate services for families and caregivers. The role involves building rapport through motivational interviewing and developing individualized care plans for high-risk patients enrolled in Health Home Plus.

You will work with hospitals, PCPs, specialists, and community resources to ensure seamless care coordination, track at-risk groups, and perform outreach in various settings to improve follow-up and access to