Care Coordination Specialist - Patient-Centered

Northwell; Melville (NY); On-site; USD 70,000 - 90,000; Full time

Job summary

Northwell Health seeks a Care Management Specialist to coordinate patient-centered care across hospitals, primary care, and community resources in Melville, NY. You will apply motivational interviewing and develop individualized care plans for high-risk patients.

You will collaborate with the care team to reduce gaps in follow-up, support adherence, and address medical and social barriers to care, with bilingual Spanish preferred.

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.
• Health home or care management experience strongly preferred.
• NYS Driver’s license strongly preferred.
• Bilingual Spanish preferred.

Responsibilities

• Utilizes patient-centered motivational interviewing techniques 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

Patient-centered care

Care coordination

Panel management

Motivational interviewing

Team collaboration

Education

Bachelor’s degree in related field

Master’s degree in related field

Job description

Northwell Health seeks a Care Management Specialist to coordinate patient-centered care across hospitals, primary care, and community resources in Melville, NY. You will apply motivational interviewing and develop individualized care plans for high-risk patients.

You will collaborate with the care team to reduce gaps in follow-up, support adherence, and address medical and social barriers to care, with bilingual Spanish preferred.