Care Coordination Specialist for High-Risk SMI Patients

Northwell Health; Massachusetts; On-site; USD 55,000 - 75,000; Full time

Job summary

Northwell Health is seeking a Care Management professional to coordinate services for high-risk patients and their families, using patient-centered approaches to connect patients with primary care, social supports, and community resources to improve access to care.

Location includes Putnam, Dutchess and Ulster counties. Applicants with CASAC or relevant degrees and 1–3 years of experience are preferred, with strong emphasis on team-based care and effective cross-setting communication.

Qualifications

• Bachelor's or Master's degree in a relevant field is strongly preferred.
• CASAC credential with two years of experience or equivalent education/experience is highly preferred.
• NYS Driver's License strongly preferred.

Responsibilities

• Uses patient-centered motivational interviewing to build rapport and improve health.
• Supports primary care by panel management to reduce care gaps and non-adherence.
• Coordinates care plans addressing medical and social barriers for high-risk patients.
• Acts as liaison between hospitals, PCPs, specialists, and community resources.
• Identifies high-risk populations and patients due for preventive or chronic care.
• Tracks discharged patients and ensures follow-up and coordination of care.

Skills

Motivational interviewing

Panel management

Care coordination

Team-based communication

Education

Bachelor's or Master's degree in relevant field

High School Diploma or equivalent

CASAC credential with 2 years experience OR Bachelor's with 3 years OR 2 years as Health Home care manager

Job description

Northwell Health is seeking a Care Management professional to coordinate services for high-risk patients and their families, using patient-centered approaches to connect patients with primary care, social supports, and community resources to improve access to care.

Location includes Putnam, Dutchess and Ulster counties. Applicants with CASAC or relevant degrees and 1–3 years of experience are preferred, with strong emphasis on team-based care and effective cross-setting communication.