Care Management Navigator for High-Risk Patients

Northwell Health; New York (NY); Presencial; USD 65.000 - 90.000; Jornada completa

Descripción de la vacante

Northwell Health is seeking a Care Management Specialist to coordinate Care Management services for families and caregivers in a Health Home Plus program. The role emphasizes patient-centered motivational interviewing and collaboration with primary care teams to improve follow-up and reduce gaps in care.

The position requires 1–3 years of relevant experience, with a BA/BS or MS/MA preferred, and a CASAC credential plus experience or equivalent BA with several years in health home care

Formación

• 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 experience OR BA with 3 years in health home care management preferred.
• NYS Driver's License strongly preferred.

Responsabilidades

• Coordinates and participates in care management activities.
• Uses patient-centered motivational interviewing to build rapport and improve health.
• Supports care team with panel management to reduce lost to care and non-compliance.
• Liaises between hospitals, primary care, specialists, and community resources for coordinated care.
• Identifies high-risk populations and tracks those discharged from inpatient or ED.
• Performs outreach in clinics, homes, hospitals, and neighborhoods to close referral loops.

Conocimientos

Motivational interviewing

Care coordination

Panel management

Interdisciplinary communication

Educación

High School Diploma or equivalent

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

CASAC credential with 2+ years experience OR BA with 3 years in health home care management

NYS Driver's License preferred

Descripción del empleo

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).