Care Management Coordinator (Putnam, Dutchess, Ulster County)

Northwell Health; Town of North Hempstead (NY); On-site; USD 65,000 - 90,000; Full time

Job summary

Northwell Health is seeking a Care Management Specialist to coordinate and participate in Care Management services for families and caregivers, particularly within Health Home Plus for populations with SMI. The role emphasizes patient-centered care, collaboration with the care team and effective linkage to community resources.

The position requires a high school diploma, 1–3 years' experience, and preferably a Bachelor's or Master's degree in a relevant field.

Qualifications

• High School Diploma or equivalent required.
• 1-3 years of relevant experience required.
• Bachelor's or Master's degree strongly preferred.
• CASAC credential with 2+ years of experience preferred, or BA with relevant experience.

Responsibilities

• Uses patient-centered motivational interviewing to build rapport and improve health outcomes.
• Supports primary care by panel management to reduce lost-to-care patients and noncompliance with follow-up.
• Liaises between hospitals, primary care, specialists and community resources for coordinated care.
• Identifies high-risk populations and those due for preventive or chronic care services.
• Tracks patients discharged from inpatient or ED settings and follows up.
• Performs outreach in clinics, homes, hospitals and neighborhoods to close gaps in care.

Skills

Motivational interviewing

Care coordination

Team-based communication

Education

Bachelor's or Master's degree in a relevant field

Tools

CASAC credential

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: Putnam, Dutchess and Ulster County

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).