Care Management Coordinator - Staten Island

Northwell Health; Town of North Hempstead (NY); On-site; USD 55,000 - 85,000; Full time

Job summary

Northwell Health's Care Management team is seeking a Health Home Plus care manager to coordinate services for families and caregivers in the Southwestern to Southern Queens area.

The role emphasizes motivational interviewing, panel management, and collaboration with hospitals, primary care, and community resources to ensure continuous, patient-centered care.

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 required experience OR Bachelor's + experience in SMI/SED population preferred.
• NYS Driver's License strongly preferred.
• Location: Southwestern to Southern Queens.

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 reduce patients lost to care and improve follow-up.
• Develops, maintains, and adjusts individualized care plans for high-risk patients addressing medical and social barriers.
• Acts as liaison between hospitals, primary care providers, specialists, and community resources to ensure patient-centered care.
• Identifies and tracks high-risk populations and those due for preventive or chronic care services.
• Performs outreach in primary care sites, homes, hospitals, and neighborhoods to close referral loops.

Skills

Motivational interviewing

Panel management

Care coordination

Communication

Education

High School Diploma or equivalent

Bachelor's degree

Master's degree

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: Southwestern to Southern Queens

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).