Care Management Coordinator (NYC/Bronx)

Northwell Health; Manhasset (NY); On-site; USD 65,000 - 90,000; Full time

Job summary

Northwell Health in the New York metro area seeks a Care Manager to coordinate Care Management services for families and caregivers. Health Home Plus is an intensive program for defined populations with SMI enrolled in HHSA.

You will apply patient-centered motivational interviewing, develop individualized care plans, and coordinate care across hospitals, primary care, and social services to improve patient outcomes.

Qualifications

• Experience with patient-centered motivational interviewing.
• Ability to develop and adjust individualized care plans for high-risk patients.
• Experience coordinating care across hospitals, primary care, and social services.
• CASAC credential or willingness to obtain is preferred; driver's license encouraged.

Responsibilities

• Uses motivational interviewing to help patients improve their health.
• Supports the care team with panel management to reduce care gaps.
• Acts as liaison among hospitals, primary care, specialists and community resources.
• Identifies high-risk populations and those due for preventive or chronic care services.
• Tracks patients discharged from inpatient or ED settings.
• Uses team-based communication to close referral loops and conduct outreach.

Skills

Motivational interviewing

Care coordination

Panel management

Communication

Team collaboration

Education

High School Diploma or equivalent

Bachelor's or Master's degree in relevant field

CASAC credential

Driver's license

Job description

Job Description

Coordinates and participates in activities related to Care Management services to family members and caregivers. Health Home Plus is an intensive Health Home care management service established for defined populations with SMI (severe mental illness) who are enrolled in HHSA.

Job Responsibility

• 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.

Job Qualification

• High School Diploma or equivalent required.
• 1-3 years of relevant experience, required.
• Bachelor's or Master's degree in relevant field strongly preferred.
• A Credentialed Alcoholism and Substance Abuse Counselor (CASAC) and two (2) years of experience; OR A Bachelor’s degree or higher in ANY field with either: three (3) years of experience, or two (2) years of experience as a Health Home care manager serving the SMI or SED population, highly preferred.
• NYS Driver's License strongly preferred.
• Location: NYC/Bronx

*Additional Salary Detail

The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future.When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).