Care Management Navigator for High-Risk Patients

Northwell; Manhasset (NY); On-site; USD 60,000 - 90,000; Full time

Job summary

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

Qualifications

• 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.

Responsibilities

• 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.

Skills

Motivational interviewing

Care coordination

Team communication

Education

High School Diploma or equivalent

Bachelor's or Master's degree preferred

CASAC credential or degree with relevant experience

Job description

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