Care Coordination Specialist for High-Risk Patients

Northwell Health; New York (NY); On-site; USD 65,000 - 85,000; Full time

Job summary

Northwell Health in Queens is seeking a Care Management professional to coordinate Health Home Plus services for high-risk populations and caregivers. You will utilize patient-centered approaches to improve access to care and support the care team with plan development.

Responsibilities include maintaining panel management, coordinating with hospitals, PCPs, specialists, and community resources, and tracking high-risk patients for preventive and chronic care needs.

Qualifications

• High School Diploma or equivalent.
• 1-3 years of relevant experience.
• Bachelor's or Master's degree strongly preferred.
• A CASAC and 2 years experience OR a BA/BS with 3 years experience in Health Home care management preferred.
• NYS Driver's License strongly preferred.
• Location: Queens.

Responsibilities

• Utilizes patient-centered motivational interviewing to build rapport and help patients improve their health.
• Supports the primary care team by providing panel management to decrease the number of patients lost to care, non-compliant in follow up care or disconnected from primary care. Participates in the development, maintenance, and adjustment of individualized care plans for high-risk patients that address both medical and social barriers to accessing care.
• Acts as a professional liaison between hospitals, primary care providers, specialists, and community resources on behalf of patients to ensure patient-centered care coordination.
• Identifies and tracks special populations, including high-risk patients and other populations due for preventive or chronic care services.
• Identifies and tracks patients discharged from the inpatient service or the emergency department.
• Uses team-based communication strategies to close the loop on referrals, hospital follow-ups and any outstanding items identified in the patient's care plan. Performs outreach activities in primary care sites, homes, hospitals, and neighborhoods.

Skills

Motivational interviewing

Panel management

Care coordination

Communication

Education

High School Diploma

Bachelor's degree

Master's degree

Job description

Northwell Health in Queens is seeking a Care Management professional to coordinate Health Home Plus services for high-risk populations and caregivers. You will utilize patient-centered approaches to improve access to care and support the care team with plan development.

Responsibilities include maintaining panel management, coordinating with hospitals, PCPs, specialists, and community resources, and tracking high-risk patients for preventive and chronic care needs.