Care Management Coordinator (Staten Island)

Northwell; Manhasset (NY); In loco; USD 60.000 - 90.000; Tempo pieno

Descrizione del lavoro

Northwell is seeking a Health Home Care Manager to coordinate care for families and caregivers enrolled in Health Home Plus for defined populations with SMI. The role emphasizes patient-centered motivational interviewing and close collaboration with primary care teams to improve follow-up and reduce gaps in care.

Responsibilities include developing holistic care plans, liaising with hospitals and community resources, and tracking high-risk patients as part of a team-based approach to care

Competenze

• A High School Diploma or equivalent is required.
• 1–3 years of relevant experience is required.
• Bachelor's or Master's degree in a relevant field is strongly preferred.
• CASAC credential with 2 years of experience, or a Bachelor's degree with 3 years in health home care management for SMI/SED populations is highly preferred.
• NYS driver's license is strongly preferred.

Mansioni

• Uses patient-centered motivational interviewing to build rapport and improve health outcomes.
• Supports the care team with panel management to reduce care gaps and non-compliance.
• Develops, maintains and adjusts individualized care plans addressing medical and social barriers to accessing care.
• Acts as liaison between hospitals, primary care providers, specialists, and community resources for patient-centered care coordination.
• Identifies and tracks high-risk populations and others due for preventive or chronic care services.
• Tracks patients discharged from inpatient or ER settings.
• Uses team-based communication to close the loop on referrals and follow-ups across care sites.

Conoscenze

Motivational interviewing

Care coordination

Team communication

Formazione

High School Diploma or equivalent

Bachelor's or Master's degree preferred

CASAC credential or degree with relevant experience

Descrizione del lavoro

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: Staten Island

*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).