Care Coordination Specialist – Patient-Centered & High-Risk

Northwell Career Site; New York (NY); On-site; USD 60,000 - 80,000; Full time

Job summary

Northwell is seeking a Care Management professional to coordinate care for families and caregivers in New York. The role emphasizes patient-centered approaches and collaboration with primary care teams to optimize follow-up and adherence.

The candidate will use motivational interviewing, develop individualized care plans, and liaise with hospitals, specialists, and community resources to ensure continuous, patient-centered care coordination. Bilingual Spanish is a plus.

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

Motivational interviewing

Panel management

Care coordination

Spanish (bilingual)

Education

Bachelor's or Master's degree in relevant field

Job description

Northwell is seeking a Care Management professional to coordinate care for families and caregivers in New York. The role emphasizes patient-centered approaches and collaboration with primary care teams to optimize follow-up and adherence.

The candidate will use motivational interviewing, develop individualized care plans, and liaise with hospitals, specialists, and community resources to ensure continuous, patient-centered care coordination. Bilingual Spanish is a plus.