Care Coordination Specialist for High-Risk Patients

Northwell Career Site; New York (NY); On-site; USD 60,000 - 90,000; Full time

Job summary

Northwell Career Site seeks a Care Manager to coordinate care for families and caregivers in New York. You will work with the primary care team, applying patient-centered motivational interviewing to improve health and engagement.

You will manage panels, develop individualized care plans addressing medical and social barriers, liaise between hospitals, PCPs, specialists, and community resources, and track high-risk patients and those recently discharged to ensure timely follow-up.

Qualifications

• High school diploma or equivalent required.
• 1-3 years of relevant experience required.
• Bachelor's or Master's degree preferred.
• Health home or care management experience preferred.
• NYS driver's license preferred.
• Bilingual Spanish preferred.

Responsibilities

• Use patient-centered motivational interviewing to build rapport and improve health.
• Support the primary care team by panel management to reduce patients lost to care.
• Develop, maintain, and adjust individualized care plans addressing medical and social barriers.
• Act as liaison between hospitals, primary care providers, specialists, and community resources.
• Identify and track high-risk populations and patients due for preventive or chronic care services.
• Identify patients discharged from inpatient or ED and ensure follow-up.

Skills

Motivational interviewing

Care coordination

Panel management

Patient-centered communication

Team-based communication

Education

Bachelor's or Master's degree in relevant field

High School Diploma or equivalent

Tools

EHR systems

Job description

Northwell Career Site seeks a Care Manager to coordinate care for families and caregivers in New York. You will work with the primary care team, applying patient-centered motivational interviewing to improve health and engagement.

You will manage panels, develop individualized care plans addressing medical and social barriers, liaise between hospitals, PCPs, specialists, and community resources, and track high-risk patients and those recently discharged to ensure timely follow-up.