Care Management Coordinator (Suffolk)

Northwell Health; Suffolk (MS); On-site; USD 65,000 - 90,000; Full time

Job summary

Northwell Health is seeking a Care Management Associate to support Health Home Plus services for defined populations in Putnam, Dutchess, and Ulster counties. Responsibilities include patient-centered outreach, coordination with primary and specialty care, and development of individualized care plans for high-risk individuals.

The role emphasizes collaboration with hospitals, PCPs, and community resources to improve access and adherence to care, while tracking high-risk patients and ensuring

Qualifications

• High School Diploma or equivalent required.
• 1-3 years of relevant experience required.
• Bachelor's or Master's degree in a relevant field strongly preferred.
• CASAC plus 2 years experience OR Bachelor's with 3 years health home care management experience preferred.
• NYS Driver's License strongly preferred.

Responsibilities

• Use motivational interviewing to build rapport and improve health.
• Provide panel management to reduce care loss and support care plans for high-risk patients.
• Coordinate with hospitals, PCPs, specialists, and community resources.
• Identify high-risk groups and patients due for preventive or chronic care services.
• Track discharged patients and ensure follow-ups.
• Close the loop on referrals and outreach in care sites, homes, and neighborhoods.

Skills

Motivational interviewing

Panel management

Care coordination

Liaison with hospitals/ PCPs

Team-based communication

Outreach in clinics/homes

Education

High School Diploma or equivalent

Bachelor's degree in relevant field

Master's degree in relevant field (preferred)

CASAC certification with 2 years experience or higher (preferred)

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).